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Identitas pasien

Nama

: Ny. Nendah

Jenis Kelamin

: Wanita

Usia

: 42 tahun

Pekerjaan

: Ibu kantin

Status
Suku

: Menikah
: Sunda

Agama

: Islam

Alamat

: Baleendah

Tanggal Pemeriksaan

: 1 Juni 2015

Keluhan utama
Bau pada hidung sebelah kiri

Anamnesis tambahan
Pasien datang ke poliklinik THT RSUD Al-Ihsan Bandung dengan keluhan
terasa bau pada hidung sebelah kiri sejak 3 tahun yang lalu yang muncul secara
tiba-tiba dan hilang timbul. Keluhan disertai sakit kepala dan pilek. Pada hidung
sebelah kiri mengeluarkan cairan kental, berwana kuning dan berbau, adanya
rasa penuh pada wajah sebelah kiri dan juga terasa nyeri terutama pada saat
menunduk seperti bersujud dan jika pasien menekan pipinya. Pasien
mengeluhkan adanya hidung tersumbat, ada dahak yang mengalir dari hidung
ke mulut, rasa mengganjal di tenggorok dan penurunan penciuman.
Pasien datang ke poliklinik THT RSUD Al-Ihsan Bandung dengan keluhan
terasa bau pada hidung sebelah kiri sejak 3 tahun yang lalu yang muncul secara
tiba-tiba dan hilang timbul. Keluhan disertai sakit kepala dan pilek. Pada hidung
sebelah kiri mengeluarkan cairan kental, berwana kuning dan berbau, adanya
rasa penuh pada wajah sebelah kiri dan juga terasa nyeri terutama pada saat
menunduk seperti bersujud dan jika pasien menekan pipinya. Pasien
mengeluhkan adanya hidung tersumbat, ada dahak yang mengalir dari hidung
ke mulut, rasa mengganjal di tenggorok dan penurunan penciuman.
Pasien menyangkal adanya penurunan pendengaran, telinga kiri terasa
penuh, dan mendengung .
Pasien tidak mempunyai riwayat asma, alergi terhadap obat, makanan,
debu ataupun cuaca dingin, riwayat operasi atau trauma pada sekitar wajah,
riwayat hipertensi, penyaki jantung, dan penyakit ginjal.
Riwayat pemakaian obat semprot hidung (dekongestan) dalam jangka
waktu lama disangkal oleh pasien.

Keluarga pasien tidak ada yang mengalami keluhan yang sama seperti
pasien. Keluarga pasien juga tidak ada yang mempunyai asma, alergi terhadap
obat-obatan, makanan, debu, ataupun cuaca dingin.
Riwayat lingkungan pasien mengaku anak dan suaminya merokok di
rumah.
Pemeriksaan fisik
Keadaan Umum

: Sakit ringan, kooperatif

Kesadaran

: Composmentis

Tinggi Badan: 155 cm


Berat Badan : 55 kg
Tanda-tanda Vital
Tekanan darah

: 110/70 mmHg

Respirasi

: 21 kali/menit

Nadi

: 74 kali / menit

Suhu

: 36.00 C

Status generalis
Kepala:
Simetris, tidak ada pembengkakan
Rambut: tidak rontok, tidak kusam
Mata: simetris, isokor, ikterik -/-, anemis -/-, allergic shiner -/Hidung: simetris, septum deviasi -, discharge , allergic salute -, allergic crease Mulut: simetris, frenulum normal, tdk ada pembesaran tonsil & uvula, lidah
bersih, geographic tongue -.
Leher : simetris, tidak ada deviasi trakea, tidak ada pembesaran KGB, JVP tdk
meningkat, thyroid tidak membesar
Dada: simetris, napas thoracoabdominal
Paru: VBS ka=ki, wheezing -/-, ronkhi -/Jantung: Bunyi jantung regular, murmur Abdomen: Lembut, datar, timpani, BU +, hepar dan lien tidak teraba
Extremitas Atas: simetris, bengkak -/-, sianosis -/-, akral hangat +/+, CR < 2S.
Extremitas Bawah: simetris, bengkak -/-, sianosis -/-, akral hangat +/+, CR < 2S.

Status lokalis :

a. Telinga

b. Hidung

c. Oral cavity

Tes transluminasi
Kesan: Adanya kesuraman sinus maksilaris sinistra
4

Inspeksi:
Pada inspeksi sinus frontalis tidak membengkak
Sinus maksilaris tidak membengkak
Palpasi:
Nyeri tekan pada sinus maksilaris sinistra
Maxillofacial
Bentuk

: simetris

Parese nervus cranialis

: (-/-)

Nyeri tekan (-/+) pada sinus maksilaris sinistra


Leher
KGB: tidak teraba membesar; pembesaran thyroid ()
Massa: (-)
DIAGNOSIS KERJA
Sinusitis maksillaris kronik sinistra e.c dentogen
USULAN PEMERIKSAAN
Pemeriksaan darah rutin: leukosit, hitung jenis
X-Ray: Waters
Hasil pemeriksaan :
X-Ray:
Ditemukan gambaran perselubungan opaque pada Sinus maksilaris sinistra
Penatalaksanaan :
ANTIBIOTIK
Amoxicillin 500mg 3x1 selama 10 hari
Metronidazole 250mg 3x1 selama 10 hari
DEKONGESTAN
Pseudoefedrin 60mg 2x1 selama 5 hari
ANALGESIK
Asam mefenamat 500mg 2x1 selama 5 hari bila perlu
MUKOLITIK
Ambroxol 30mg 2x1 selama 5 hari

TINDAKAN OPERASI
Operasi Caldwell-Luc
Anatomi sinus
Terdapat empat pasang sinus paranasal mulai dari yang terbesar yaitu sinus
maksila, sinus frontal, sinus ethmoid dan sinus sfenoid kanan dan kiri.
Sinus paranasal merupakan hasil pneumatisasi tulang-tulang kepala sehingga
terbentuk rongga di dalam tulang.

Embriologi
Secara embriologik sinus paranasal berasal dari invaginasi mukosa rongga
hidung dan perkembangannya dimulai pada fetus usia 3-4 bulan kecuali sinus
sfenoid dan frontal.
Sinus frontal berkembang dari sinus ethmoid anterior pada anak yang berusia
sekitar 8 tahun.
Sinus sfenoid mulai mengalami pneumatisasi antara usia 8-10 tahun dan berasal
dari rongga hidung bagian posterosuperior

Etmoid

Sinus ethmoid posterior bermuara


meatus superior.

Sfenoid

Sinus sfenoid bermuara ressesus


sfenoethmidalis.

Semua sinus mempunyai muara ke


dalam rongga hidung. Sinus maksila,
ethmoid anterior dan frontal
bermuara meatus media

Maksila
dan
frontal

Sinus maxilla
sinus paranasal terbesar. 6-8 ml saat lahir dewasa 15 ml.
Sinus ini berbentuk segitiga dan dibatasi di bagian anterior oleh permukaan
fasial os maksila (fosa canina), bagian posterior permukaan infratemporal
maksila, dinding medialnya dinding lateral rongga hidung, dinding superiornya
dasar orbita dan bagian inferiornya adalah prosessus alveolaris serta palatum.
Ostium sinus maksila berada di sebelah superior dinding medial sinus dan
bermuara ke hiatus semilunaris melalui infundibulum ethmoid.

Secara klinis yang perlu diperhatikan dari sinus maksila adalah :


1) dasar sinus maksila sangat berdekatan dengan akar gigi rahang atas yaitu
premolar (P1, P2) molar (M1, M2) kadang-kadang gigi taring (C) atau gigi molar
M3. Infeksi gigi sinusitis
2) sinusitis maksila dapat menimbulkan komplikasi ke orbita
3) ostium sinus maksila terletak lebih tinggi dari dasar sinus sehingga drainase
kurang baik.
Sinus frontal :
Bulan ke empat sel-sel resesus frontal atau dari sel-sel infundibulum ethmoid.
Sinus frontal kanan dan kiri biasanya tidak simetris, dipisahkan oleh sekat
berupa tulang yang relatif tipis dari orbita dan fosa cerebri anterior sehingga
infeksi dari sinus frontal mudah menyebar ke daerah ini.
Kurang lebih 15% orang dewasa hanya mempunyai satu sinus frontal dan
kurang lebih 5% sinus frontalnya tidak berkembang.
berlekuk-lekuk, tidak lekuk-lekuk ~ infeksi.

lebar 2,4 cm tinggi 2,8 cm dan dalamnya 2 cm.


Sinus ethmoid :
fokus infeksi bagi sinus-sinus lainnya.
ukuran dari anterior ke posterior 4-5 cm, tinggi 2,4 cm dan lebarnya 0,5 cm di
bagian anterior serta 1,5 cm di bagian posterior.
sel-sel menyerupai sarang tawon. Sel-sel sinus ethmoid anterior biasanya lebih
kecil dan lebih padat dibandingkan di bagian posterior sinus. Berdasarkan
letaknya sinus ethmoid dibagi menjadi sinus ethmoid anterior meatus media
dan sinus ethmoid posterior meatus superior.
Sel etmoid terbesar disebut bula etmoid. Terdapat infundibulum (penyempitan)
pada etmoid anterior tempat muaranya ostium sinus maksila.
Dinding lateral sinus adalah lamina papirasea yang sangat tipis dan membatasi
sinus ethmoid dari rongga orbita. Bagian belakang sinus ethmoid posterior
berbatasan dengan sinus sfenoid.

Sinus sphenoid
Sinus sfenoid terletak dalam os sfenoid yang terpisah menjadi dua oleh sekat
septum intersfenoid.
tinggi 2 cm, dalamnya 2,3 cm dan lebarnya 1,7 cm. 5-7, 5 ml.
Sebelah superior dibatasi fossa cerebri media dan kelenjar hipofise, sebelah
inferior atap nasofaring, lateralnya dibatasi sinus cavernosus dan arteri carotis
interna (sering tanpak sebagai indentasi) dan sebelah posterior terdapat fossa
cerebri posterior di daerah pons.
Kompleks ostio-meatal

Pada sepertiga tengah dinding lateal hidung yaitu di meatus medius, ada muaramuara saluran dari sunis maksila, sinus frontal dan sinus etmoid anterior. Daerah
ini rumit dan sempit, dan dinamakan kompleks ostio-meatal (KOM)

Sistem mukosiliari
Seperti pada mukosa hidung, di dalam sinus juga terdapat mukosa bersilia dan
palut lendir diatasnya. Di dalam sinus silia bergerak secara teratur untuk
mengalirkan lendir menuju ostium alamiahnya mengikuti jalur-jalur yang sudah
tertentu polanya.
Histologi
Epitel respirasi (epitel bertingkat silidris bersilia) yang lebih tipis yang
mengandung sedikit sel goblet
Lamina propria mengandung beberapa kelenjar kecil dan berhubungna langsung
dengan periosteum dibawahnya
Fisiologi
Sebagai pengatur kondisi udara (air conditoning)
Sebagai penahan suhu (Thermal Insulators)
Membantu keseimbangan kepala, karena mengurangi berat tulang muka
Membantu resonansi suara
Membantu produksi mucus

Sinusitis
Etiologi
Terdapat 2 faktor yaitu infeksius dan nonifeksius yang dapat memberikan
kontribusi dalam terjadinya obstruksi akut ostia sinus atau gangguan
pengeluaran cairan oleh silia, yang akhirnya menyebabkan sinusitis.
Penyebab nonifeksius antara lain adalah rinitis alergika, barotrauma, atau iritan
kimia. Penyakit seperti tumor nasal atau tumor sinus (squamous cell carcinoma),
dan juga penyakit granulomatus (Wegeners granulomatosis atau rhinoskleroma)
juga dapat menyebabkan obstruksi ostia sinus, sedangkan konsisi yang
menyebabkan perubahan kandungan sekret mukus (fibrosis kistik) dapat
menyebabkan sinusitis dengan mengganggu pengeluaran mukus.
Pada dasarnya patofisiologi dari sinusitis dipengaruhi oleh 3 faktor yaitu
obstruksi drainase sinus (sinus ostia), kerusakan pada silia, dan kuantitas dan
kualitas mukosa
Faktor predisposisi

ISPA akibat virus

Rhinitis terutama rhinitis alergi

Rhinitis hormonal pada ibu hamil

Polip hidung

Kelainan anatomi seperti deviasi septum atau hipertrofi konka

Sumbatan kompleks ostio-meatal (KOM)

Infeksi tonsil

Infeksi gigi

Kelainan imunologi

Lingkungan berpolusi

Udara dingin dan kebiasaan merokok

Patogenesis dan patofisiologi


Adanya sumbatan pada ostium sinus
Retensi seksresi mukus, tekanan sinus menjadi negatif dan kurangnya parsial
oksigen
Menjadi area patogen untuk mempermudah perkembangan mikroorganisme
(bakteri,virus, jamur)
Bakteri bermultiplikasi dan menjadi purulen

TANDA DAN GEJALA

Nasal obstruction, blockage, congestion, stuffiness


Nasal discharge (of any character from thin to thick and from clear to purulent)
Postnasal drip
Facial fullness, discomfort, pain, and headache (more with nasal polyposis)
Chronic unproductive cough (primarily in children)
Hyposmia or anosmia (more with nasal polyposis)
Sore throat
Fetid breath
Malaise
Easy fatigability
Anorexia
Exacerbation of asthma
Dental pain (upper teeth)
Visual disturbances
Sneezing
Stuffy ears
Unpleasant taste
Fever of unknown origin

DIAGNOSIS

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
An endoscopic view of the nasal cavity can be seen below.

Endoscopic view right nasal cavity; lacrimal bone (L), uncinate process (U),
ethmoid bulla (B), middle turbinate (MT), nasal septum (S).

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:

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 laryngealpharyngeal 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.[19] 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.

In 1996, the American Academy of Otolaryngology-Head & Neck Surgery convened a multidisciplinary
Rhinosinusitis Task Force (RTF). This group defined adult rhinosinusitis diagnostic criteria.[3] 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).
In 2003, the RTFs definition was amended to require confirmatory radiographic or nasal endoscopic or physical
examination findings in addition to suggestive history.[4]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.[20]
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:[21]

Anterior or posterior mucopurulent drainage


Nasal obstruction
Facial-pain-pressure-fullness
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.

DD
Problems to be considered include the following:

Temporomandibular joint syndrome


Asthma
Other chronic rhinitis
Nasal and sinus cavity tumors
Facial pain and headache attributable to other causes
Nasal polyp
Dental infection
Periodontal abscess
Antral-choanal polyp
Inverting papilloma
Aspirin/nonsteroidal anti-inflammatory drug sensitivity
Chronic headache of other etiology

Differential Diagnoses

Allergic Fungal Sinusitis


Cystic Fibrosis
Fever of Unknown Origin
Foreign Bodies of the Airway
Gastroesophageal Reflux Disease
Juvenile Nasopharyngeal Angiofibroma
Malignant Nasopharyngeal Tumors
Malignant Tumors of the Nasal Cavity
Malignant Tumors of the Sinuses
Nonallergic Rhinitis
Olfaction disorders
Pain due to other causes (migraine, tension headaches, and cluster headaches, and facial pain
syndromes)
Rhinitis, Allergic
Rhinocerebral Mucormycosis
Sinusitis
Sinusitis, Acute
Sinusitis, Acute, Medical Treatment
Sinusitis, Chronic, Medical Treatment
Sinusitis, Fungal
Skull Base, Benign Tumors
Turbinate Dysfunction

Sinusitis Kronik
Sinusitis kronis berbeda dari sinusitis akut dalam berbagai aspek, umumnya
sukar disembuhkan dengan pengobatan medikamentosa saja. Harus dicari faktor
penyebab dan faktor predisposisinya.
Polusi bahan kimia menyebabkan silia rusak, sehingga terjadi perubahan
mukosa hidung dapat juga disebabkan oleh alergi dan defisiensi imunologik. Perubahan
mukosa hidung akan mempermudah terjadinya infeksi dan infeksi menjadi kronis apabila
pengobatan pada sinusitis akut tidak sempurna. Adanya infeksi akan menyebabkan
edema konka, sehingga drenase sekret akan terganggu. Drenase sekret yang
terganggu dapat menyebabkan silia rusak dan seterusnya.

Gejala Subyektif
Gejala subyekif sangat bervariasi dari ringan sampai berat, terdiri dari:
Gejala hidung dan nasofaring, berupa sekret di hidung dan sekret pasca nasal drip (post nasal

drip).
Gejala faring, yaitu rasa tidak nyaman dan gatal di tenggorok.
Gejala telinga, berupa pendengaran terganggu oleh karena tersumbatnya tuba Eustachius.
Adanya nyeri/sakit kepala.
Gejala mata, oleh karena penjalaran infeksi melalui duktus naso-lakrimalis.
Gejala saluran napas berupa batuk dan kadang-kadang terdapat komplikasi di paru, beruoa
bronchitis atau bronkietaksis atau asma bronchial, sehingga terjadi penyakit sinobronkitis.
Gejala di saluran cerna, oleh karena mukopus yang tertelan dapat menyebabkan
gastroenteritis,`sering terjadi pada anak.
Kadang-kadang gejala sangat ringan hanya terdapat sekret di nasofaring yang
meengganggu pasien. Sekret pasca nasal yang terus-menerus akan mengakibatkan
batuk kronik.
Nyeri kepala pada sinusitis kronis biasanya terasa pada pagi hari dan akan
berkurang atau hilang setelah siang hari. Penyebabnya belum diketahui dengan pasti,
tetapi mungkin karena pada malam hari terjadi penimbunan ingus dalam rongga hidung
dan sinus serta adamya stasis vena.
Gejala obyektif
Pada sinusitis kronis, temuan pemeriksaan klinis tidak seberat sinusitis akut dan
tidak terdapat pembengkakan pada wajah. Pada rinoskopi anterior dapat ditemukan
sekret kental purulen dari meatus medius atau meatus superior. Pada rinoskopi posterior
tampak sekret purulen di nasofaring atau turun ke tenggorok.
Pemeriksaan mikrobiologik
Biasanya merupakan infeksi campuran oleh bermacam-macam mikroba, seperti
kuman
aerobS.
aureus, S.
viridians, H.
Influenzae dan
kuman
anaerob
Peptostreptokokus dan Fusobakterium.

Diagnosis sinusitis kronik


Dibuat berdasarkan anamnesis yang cermat, pemeriksaan rinoskopi anterior dan
posterior serta pemeriksaan penunjang berupa transiluminasi untuk sinus maksila dan
sinus frontal, pemeriksaan radiologik, pungsi sinus maksila, sinoskopi sinus maksila,
pemeriksaan histopatologik dari jaringan yang diambil pada waktu dilakukan sinoskopi,
pemeriksaan meatus medius dan meatus superior dengan menggunakan nasoendoskopi dan pemeriksaan CT-scan.
Terapi
Pada sinusitis kronis perlu diberikan terapi antibiotik untuk mengatasi infeksinya
dan obat-obatan simtomatis lainnya. Antibiotik diberikan selama sekurang-kurangnya 2
minggu. Selain itu dapat juga dibantu dengan diatermi gelombang pendek selama 10
hari di daerah sinus yang sakit.
Tindakan lain yang dapat dilakukan ialah tindakan untuk membantu memperbaiki
drenase dan pembersihan sekret dan sinus yang sakit. Untuk sinusitis maksila
dilakukan pungsi dan irigasi sinus, sedangkan untuk sinusitis etmoid, frontal atau
sphenoid dilakukan tindakan pencucian Proetz. Irigasi dan pencucian sinus ini
dilakukan 2 kali dalam seminggu. Bila setelah 5-6 kali tidak ada perbaikan dan klinis
masih tetap banyak sekret purulen, berarti mukosa sinus sudah tidak dapat kembali
normal (perubahan irreversible), maka perlu dilakukan operasi radikal.
Untuk mengetahui perubahan mukosa masih reversible atau tidak, dapat juga
dilakukan dengan pemeriksaan sinoskopi, yaitu melihat antrum (sinus maksila) secara
langsung dengan menggunakan endoskop.
Komplikasi Sinusitis
CT-Scan penting dilakukan dalam menjelaskan derajat penyakit sinus dan derajat
infeksi di luar sinus, pada orbita, jaringan lunak dan kranium. Pemeriksaan ini harus rutin
dilakukan pada sinusitis refrakter, kronis atau berkomplikasi.
1. Komplikasi orbita
Sinusitis ethmoidalis merupakan penyebab komplikasi pada orbita yang tersering.
Pembengkakan orbita dapat merupakan manifestasi ethmoidalis akut, namun sinus frontalis
dan sinus maksilaris juga terletak di dekat orbita dan dapat menimbulkan infeksi isi orbita.
Terdapat lima tahapan :
Peradangan atau reaksi edema yang ringan. Terjadi pada isi orbita akibat infeksi sinus

ethmoidalis didekatnya. Keadaan ini terutama ditemukan pada anak, karena lamina papirasea
yang memisahkan orbita dan sinus ethmoidalis sering kali merekah pada kelompok umur ini.
Selulitis orbita, edema bersifat difus dan bakteri telah secara aktif menginvasi isi orbita
namun pus belum terbentuk.
Abses subperiosteal, pus terkumpul diantara periorbita dan dinding tulang orbita
menyebabkan proptosis dan kemosis.

Abses orbita, pus telah menembus periosteum dan bercampur dengan isi orbita. Tahap ini
disertai dengan gejala sisa neuritis optik dan kebutaan unilateral yang lebih serius.
Keterbatasan gerak otot ekstraokular mata yang tersering dan kemosis konjungtiva
merupakan tanda khas abses orbita, juga proptosis yang makin bertambah.
Trombosis sinus kavernosus, merupakan akibat penyebaran bakteri melalui saluran vena
kedalam sinus kavernosus, kemudian terbentuk suatu tromboflebitis septik.
Secara patognomonik, trombosis sinus kavernosus terdiri dari :
a. Oftalmoplegia.
b. Kemosis konjungtiva.
c. Gangguan penglihatan yang berat.
Tanda-tanda meningitis oleh karena letak sinus kavernosus yang berdekatan dengan saraf
kranial II, III, IV dan VI, serta berdekatan juga dengan otak.
2. Mukokel
Mukokel adalah suatu kista yang mengandung mukus yang timbul dalam sinus, kista ini
paling sering ditemukan pada sinus maksilaris, sering disebut sebagai kista retensi mukus dan
biasanya tidak berbahaya.
Dalam sinus frontalis, ethmoidalis dan sfenoidalis, kista ini dapat membesar dan melalui
atrofi tekanan mengikis struktur sekitarnya. Kista ini dapat bermanifestasi sebagai
pembengkakan pada dahi atau fenestra nasalis dan dapat menggeser mata ke lateral. Dalam
sinus sfenoidalis, kista dapat menimbulkan diplopia dan gangguan penglihatan dengan
menekan saraf didekatnya.
Piokel adalah mukokel terinfeksi, gejala piokel hampir sama dengan mukokel meskipun
lebih akut dan lebih berat.
Prinsip terapi adalah eksplorasi sinus secara bedah untuk mengangkat semua mukosa
yang terinfeksi dan memastikan drainase yang baik atau obliterasi sinus.
3. Komplikasi Intra Kranial
Meningitis akut, salah satu komplikasi sinusitis yang terberat adalah meningitis akut, infeksi
dari sinus paranasalis dapat menyebar sepanjang saluran vena atau langsung dari sinus yang
berdekatan, seperti lewat dinding posterior sinus frontalis atau melalui lamina kribriformis di
dekat sistem sel udara ethmoidalis.
Abses dural adalah kumpulan pus diantara dura dan tabula interna kranium, sering kali
mengikuti sinusitis frontalis. Proses ini timbul lambat, sehingga pasien hanya mengeluh nyeri
kepala dan sebelum pus yang terkumpul mampu menimbulkan tekanan intra kranial.
Abses subdural adalah kumpulan pus diantara duramater dan arachnoid atau permukaan
otak. Gejala yang timbul sama dengan abses dura.
Abses otak, setelah sistem vena, dapat mukoperiosteum sinus terinfeksi, maka dapat terjadi
perluasan metastatik secara hematogen ke dalam otak. Terapi komplikasi intra kranial ini
adalah antibiotik yang intensif, drainase secara bedah pada ruangan yang mengalami abses
dan pencegahan penyebaran infeksi.

4. Osteomielitis dan abses subperiosteal


Penyebab tersering osteomielitis dan abses subperiosteal pada tulang frontalis adalah
infeksi sinus frontalis. Nyeri tekan dahi setempat sangat berat. Gejala sistemik berupa
malaise, demam dan menggigil

WORKUP

Approach Considerations
Always consider serious underlying conditions, such as tumors and immunodeficiency states, in the workup. In
general, plain radiography has low sensitivity and specificity. CT scanning is considered the imaging standard for
evaluation of chronic sinusitis. Routine blood cell counts and sedimentation rates are generally unhelpful;
however, these may be elevated in patients with fever.
The cornerstone in the diagnostic workup of chronic sinusitis is the radiologic examination. Nasal endoscopy is
recommended in most cases prior to obtaining imaging because it demonstrates the condition of the nasal
mucosa and evaluates for purulent drainage.
Radiographic findings in individuals with chronic sinusitis may demonstrate osteoblastic response in the affected
sinus walls, mucoperiosteal thickening, opacification of sinus cavity, and even reduction of cavity size. Younger
children with persistent respiratory symptoms probably have significant abnormalities that are observable on
sinus radiographs. These radiographs provide noninvasive and rapid evaluation of the lower third of the nasal
cavity and of the maxillary, frontal, sphenoid, and posterior ethmoid sinuses. Unfortunately, these views provide
only limited information about anterior ethmoid anatomy and may be misleading in soft-tissue inflammatory
disease; hence, more physicians are using CT for preoperative evaluation and MRI for excluding orbital and
intracranial extension.[20]
For more information, see the Medscape Reference article Imaging in Sinusitis.

Lund-Mackay scale for evaluation of images


Various staging systems have been proposed; however, no one system is accepted as the standard for use in
chronic rhinosinusitis (CRS). Many studies use the Lund-Mackay scale to evaluate radiographic images. This
scale grades the right and left sides independently, looking at the maxillary, anterior ethmoids, posterior
ethmoids, sphenoid, and frontal sinuses, as well as the ostiomeatal complex. Each sinus is scored a 0 (no
abnormality), 1 (partial opacification), or 2 (total opacification), while the ostiomeatal complex is scored either a 0
or 2 (for presence or absence of disease). Scores range from 0-24.

Cultures
Establishing the presence of sinus infection requires obtaining bacterial and fungal cultures. These can be
obtained directly from the sinus cavity (by maxillary sinus tap or during surgery) or endoscopically from the ostia.
Studies of chronic sinusitis have demonstrated no correlation between nasal flora and culture from the sinuses.
Nasal swab cultures have therefore no diagnostic value. In severe cases, blood cultures, including fungal blood
cultures, may be helpful.

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.

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 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 meta-analysis.[22]

Imaging Studies
Plain radiography may show mucosal thickenings or sinus opacities. However, it is not adequate to diagnose
chronic rhinosinusitis because abnormalities detected on plain films are not sensitive or specific for sinusitis. Air
fluid levels are uncommon in chronic sinusitis. Ethmoid sinuses and the ostiomeatal complex are not visualized
well on plain sinus radiography. For more information, see the Medscape Reference article Imaging in Sinusitis.
Multiplanar sinus CT scan is the preferred imaging technique for evaluating chronic rhinosinusitis. Sinusitis is
characterized by the presence of sinus mucosal thickening, sinus ostial obstruction, and sinus opacification.
Other findings include polyps, mucoceles, and bony changes due to chronic rhinosinusitis (sclerosis, septations,
erosions, and bowing).
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.
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.

Other Tests

Environmental allergen evaluation should be considered. Radioallergosorbent assay test (RAST) or skin testing
for allergens may play an important role in treating patients with chronic rhinosinusitis (CRS) and confounding
allergies. Perform allergy testing if allergy is thought to be the underlying cause.
Associated immune deficiency is evaluated with serum immunoglobulin and IgG subclass determination,
antibody response to specific antigens, and HIV antibody testing (when indicated).
A sweat test for cystic fibrosis should be considered in all children with nasal polyposis and CRS.
Total immunoglobulin E (IgE) levels, as well as the degree of staining of IgE in sinus epithelium and
subepithelium, can be tested and may be helpful to evaluate for allergic fungal sinusitis.[23]

TREATMENT
The goals of medical therapy for CRS are to reduce mucosal edema, promote sinus drainage, and eradicate
infections that may be present. This often requires a combination of topical or oral glucocorticoids, antibiotics,
and nasal saline irrigation. If these measures fail, the patient should be referred to an otolaryngologist for
consideration of sinus surgery. The role of bacteria in the pathogenesis of chronic sinusitis remains debatable;
however, an early diagnosis and intensive treatment with oral antibiotics, topical nasal steroids, decongestants,
and saline nasal sprays results in symptom relief in a significant number of patients, many of whom can be cured.
When medical therapy is unsuccessful, refer the patient for surgical evaluation.
Tujuan terapi sinusitis kronik adalah untuk reduksi edema mukosa, drainase sinus dan eradikasi infeksi bila ada.
Biasanya memerlukan kombinasi obat kortikosteroid, antibiotic dan irigasi nasal. Bila gagal maka akan
dipertimbangkan untuk operasi sinus.
Inpatient treatment of chronic sinusitis is indicated for patients with orbital and intracranial complications.
Immunosuppressed patients and pediatric patients with chronic sinusitis may need inpatient care, depending on
the severity of the disease.

Control of Predisposing Factors


Because chronic sinusitis has many risk factors and potential etiologies, apply a combined approach to control or
modify these factors in the management of chronic sinusitis.

Viral upper respiratory tract infections


Reduce viral exposures by improved personal hygiene. The roles of zinc and vitamin C in the prevention of viral
upper respiratory tract infection are controversial. On June 16, 2009, the US Food and Drug Administration (FDA)
issued a public health advisory and notified consumers and health care providers to discontinue the use of
intranasal zinc products.[24] The intranasal zinc products (Zicam Nasal Gel/Nasal Swab; Matrixx Initiatives) are
herbal cold remedies that claim to reduce the duration and severity of cold symptoms and are sold without a
prescription. The FDA received more than 130 reports of anosmia (ie, an inability to detect odors) associated with
intranasal zinc. Many of the reports described the loss of smell with the first dose.

Environmental and allergic factors


Environmental factors and/or allergic factors may predispose some individuals to chronic sinusitis. Reduce
exposure to dust, molds, cigarette smoke, and other environmental chemical irritants. For patients with
confounding nasal allergy, other antiallergy therapies, including either oral or topical antihistamines, cromolyn,
topical steroids, and immunotherapy, may reduce recurrences and symptoms of allergic rhinitis.
Smoking cessation likely plays a large role in the success of both medical and surgical treatments because
tobacco products act as an irritant to normal nasal mucosa and cilia function.

Gastroesophageal reflux disease

Patients with adult chronic sinusitis may benefit from control of gastroesophageal reflux disease (GERD), which
has increasingly been implicated in causing or exacerbating respiratory ailments such as asthma and chronic
sinusitis. The exact relationships and mechanisms are presently a matter of speculation.

Immunodeficiency
Appropriate control of various congenital and acquired immunodeficiency states is necessary to cure chronic
sinusitis.

Asthma
Especially for patients with co-existing asthma, leukotriene inhibitors may play a role.

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.[25]
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.[26]
To see complete information on Balloon Sinuplasty, please go to the main article by clicking here.

Antimicrobial Therapy
Antibiotic adekuat biasanya 3-4 minggu. Pengobatan harus melingkupi antibiotic aerob
dan anaerob. Kombinasi amoksisilin dengan asam klavulanat, metronidazole dengan
makrolid atau sefalosporin atau kuinolon.
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.
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 methicillinresistant 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), 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.
Agents that provide coverage for MRSA should be administered. Some options include tetracyclines,
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.[27]
It is useful to tailor therapy to the clinical type of CRS.[28] CRS without nasal polyps is treated with prednisone 2040 mg daily tapered over 10 days plus an intranasal steroid. Antibiotic therapy is often required for up to 6 weeks
or longer and should not be discontinued until the patient is asymptomatic. Discontinuation of antimicrobial
therapy prior to complete resolution increases the likelihood of relapse.
Nebulized antibiotics and antifungal agents be used in refractory cases, especially in patients who have
undergone sinus surgery and as a means to avoid prolonged therapy with intravenous antibiotics. Further studies
need to be done to establish their role in treating CRS.[29]
In individuals with CRS with nasal polyps, the major intervention is to relieve the obstruction to sinus drainage by
reducing or eliminating the polyp. This is achieved primarily with glucocorticosteroids, both systemically and
intranasally. Antileukotriene agents can be adjunctive to the effect of the steroids, especially in patients with
asthma or an allergy to aspirin.[30]
There is a high rate of S aureus colonization of the sinus mucosa in CRS with nasal polyps. Three weeks of
doxycycline therapy has been demonstrated to reduce polyp size, possibly because of the anti-inflammatory
properties of the tetracyclines, as well as their anti-staphylococcal effects.[31]
Failure to relieve the polyposis obstruction with medical therapy is an indication for a surgical approach.
Fungal CRP is primarily treated with appropriate surgery (see below).

Surgical Care
Functional Endoscopic Sinus Surgery
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. Preoperative CT
findings prior to sinus surgery may be poor predictors of surgical outcomes.[32]
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.[33]
FESS facilitates the removal of disease in key areas, restores adequate aeration and drainage of the sinuses by
establishing patency of the ostiomeatal complex, debulks severe polyposis, 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 work-related exposure to inhaled
agents, and revision surgery may be required.[34]
For more information, see the Medscape Reference article Functional Endoscopic Sinus Surgery.

Management of Chronic Maxillary Sinusitis


Three main surgical options are available for chronic maxillary sinusitis:

Endoscopic uncinectomy with or without maxillary antrostomy


Caldwell-Luc procedure
Inferior antrostomy (naso-antral window)

Management of Fungal Sinusitis


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. Prolonged postoperative tapering doses of prednisone and anterior nasal glucocorticoid steroids are
indicated to suppress the symptoms of fungal CRS.
Some literature has suggested that topical antifungals may have a role in the treatment of CRS[35] ; however, this
treatment remains controversial, and other studies have not supported this approach. A recent assessment that

included 6 studies (N = 380) showed no statistically significant benefit of topical or systemic antifungals over
placebo for the treatment of CRS.[36]

Dietary Measures
Garlic has an active ingredient (allyl thiosulfinate) that provides a short-term decongestant effect. Eating foods
highly seasoned with garlic has been considered therapeutic. Chewing horseradish root is another home remedy
reported by some patients as effective for clearing the sinuses, but no scientific data support this belief.

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.
Patients should be urgently referred to an otolaryngologist when they manifest any of these signs and/or
symptoms: double or reduced vision, proptosis, rapidly developing periorbital edema, ophthalmoplegia, focal
neurologic signs, high fever, severe headache, meningeal irritation, or significant or recurrent nose bleeding.[18]
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.[18]
Other complications include osteomyelitis and mucocele formation.
Some studies have suggested a higher incidence of complications associated with fungal sinusitis.[37, 38] Untreated
chronic sinusitis can lead to life-threatening complications, as in patients with cystic fibrosis.[39]

Consultations
Persistent or recurrent episodes of sinusitis despite appropriate medical therapy necessitate referral to an
otolaryngologist. Examination, including nasal endoscopy and CT scanning, is mandatory to exclude surgically
amenable conditions.
A consult with an otolaryngologist should be considered when one of the following occurs:

The disease is refractory to maximal medical therapy.


The disease has progressed beyond the paranasal sinuses.
The disease is unilateral (patient should be evaluated for potential neoplasm).
Patients have coexisting morbidities that are exacerbated by the sinus disease.
Urgent referral when a complication is suspected (see above)
Seek consultation with an ophthalmologist at the earliest suggestion of orbital involvement. Seek consultation
with a dentist when an odontogenic infection is present or suspected.

Long-term Monitoring
Continued outpatient medical treatment with nasal decongestants and topical steroids is important even after
surgical treatment.
Nasal douching may improve symptoms, particularly following surgical treatment. Steam inhalation may have a
role to liquefy and soften crusts while moisturizing dry inflamed mucosa.
Nasal cavity irrigation using buffered normal saline may have a role in decreasing mucosal edema. Irrigation
should be performed at least twice daily.
Patients with presumed allergic rhinitis in conjunction with chronic sinusitis may benefit from an evaluation by an
otolaryngologist trained in otolaryngic allergy or an allergist/immunologist. In most instances, prick/puncture tests
are performed to clarify the role of allergies.