4 SINUS PARA NASAL 1. Sinus Frontal 2. Sinus Sphenoid 3. Sinus Ethmoid 4. Sinus Maksila
Terbesar, piramid Basis : dinding lateral rgg hidung Apek : proc Zygomatikus
Batas2 :
Anterior : permk fasial sinus maksila Posterior : fosa infra temporal & Pterigomaksila Medial : dinding lateral hidung Superior : dasar orbita Inferior : proc alveolaris & palatum
Anatomi klinik
Dasar sinus dekat dengan gigi PM 1 & 2 Batas superior dekat mata Osteum sinus lebih tinggi dari dasarnya Diameter ostium 1-3mm
Terbentuk sejak lahir Pada anak : dasar sama / > tinggi dari dasar rongga hidung Ukuran Sinus
Lahir : 7-8 x 4-6 mm Dewasa : Medio lateral : 3-5 cm Antero posterior : 2-5 cm Volume : 15-30 mL
Vaskularisasi :
Sempurna usia > 8 tahun Batas dengan orbita tipis Muara di meatus medius
3-16 Sel-sel ( sarang lebah ) volume total 3 ml Letak : bula ethmoid, diantara konka media & ddng medial orbita Jumlah : 2 kelompok
S. Ethmoid anterior muara meatus media S. Ethmoid posterior muara meatus superior
Batas batasnya
: fosa cerebri media : atap nasofaring : sinus cavernosus & a. carotis interna Posterior : Pons / fosa cerebri posterior
Komplek ostiomeatal
Celah sempit yg merupakan unit drainase fungsional ta : 1. bula ethmoid, 2. prosesus uncinatus, 3. infundibulum ethmoid, 4. hiatus semilunaris, 5. ostium sinus maksila, 6. resesus frontalis
Inflamasi pada satu atau lebih mukosa sinus paranasal baik karena infeksi dan non infeksi dg gejala : * hidung buntu, * nyeri fasial dan ingus kental /purulen.
SINUSITIS
American Academy of Otolaryngology Head and Neck Surgery ( 1996 ) : Sinusitis Rinosinusitis
Alasan : Mukosa hidung & sinus secara embriologis berhub Pend sinusitis juga rinitis ( jarang yang tidak) Gjl pilek, hidung buntu, hiposmia ada pd keduanya CT pend C Cold inflamasi mukosa hdng & sinus Kasus sinusitis lanjutan dari sinusitis
SINUSITIS
penting untuk :
Dengan C.T.
SIKLUS SINUSITIS
Faktor predisposisi
Berbagai kondisi yang mengarah pada obstruksi
sinus : infeksi & alergi Berbagai variasi anatomis : septum deviasi, konka bulosa, Kurvatura paradoksal konka media Gangguan klirens mukosilia : sindrom diskinesia (
Anamnesis
Sering dianggap pilek biasa yg tak kunjung hilang Ingus kental, sepanjang hari Suara kadang sengau / nasolalia klausa Sakit kepala, sesuai lokasi sinus yang sakit Batuk, terutama pada anak Foetor ex nasi
TANDA MAYOR 1. Nyeri pada daerah muka 2. Hidung buntu. 3. Ingus berwarna. 4. Gangguan penghidu. 5.Sekret mucopurulen 6.Demam TANDA MINOR 1. Batuk. 2. tenggorok berlendir 3. nyeri kepala 4. nyeri geraham serta napas bau
Pemeriksaan faring :
Mayor
Rhinorhe purulen Drainase post nasal
Minor
demam nyeri kepala dan sinus foetor
Batuk
Sinusitis : 2 mayor
1 mayor + 2 / lebih minor
SINUSITIS ?
Dua gejala mayor atau lebih, atau Satu gejala mayor disertai 2 gejala minor
Sinusitis Akut
Antibiotika spektrum luas
Sinusitis Kronik
- Antibiotika sesuai hasil kultur - Dekongestan hidung - Mukolitik minimal 10-14 hari tak terkontrol ? * Irigasi sinus (maks 5x) tak sembuh ? FESS Operasi Cald-Well-Luc (CWL)
ALLERGIC RHINITIS :
The most prevalent of type I allergic dis. The symptoms and signs caused by mediators : vessels, glands and nerves. Classified as inflammatory disease.
Allergic salute
Low pervalence : Indonesia, Georgia, Greece Semarang (2002) ISAAC phase 3, RA : 18,6% High pervalence : Australia, UK and Latin America In adults : no equivalent to ISAAC study National survey : 5.9 % France and 29 % UK
1.
INTERMITTENT
Less than 4 days a week, or Less than 4 weeks
2.
PERSISTENT
More than 4 days a week, and More than 4 weeks
1.
2.
B cell
IL4 Chronic ongoing rhinitis
Th2 cell
IL 3, 5, GMCSF
eosinophils
PLA2 AA + PAF
C.O 5 L.O
PGD2
LTB
DEGRADATION
Vascular wall
CNS
Itch. Systemic Reflexes Sneeze Allergic Salute Parasympathic Reflexes Glandular Exocytosis
Vasodilatation
Serous/Mucous Secretion
(+)
NARES
(-)
allergic Rhinitis ?
1.
Anamnesis
Chief complain :
1. Anamnesis
The symptoms was environment related History of other allergic manifestation of patients and other allergic familial manifestations Duration of illness, severity of the disease and the respond of the previous treatment
2. Physical examination
Should be performed with appropriate lighting and use of nasal speculum
normal
oedema
2. Physical examination
Including :
4. Secretion
5. Septum 6. Polyps ? 7. Sinusitis ?
3. Nasal cytology
Large number of eosinophils may aid to differentiate AR & NARES from other Rhinitis
No consensus to routinely performed for evaluation of rhinitis
4. Total serum Ig E
Based on a history of AR symptoms provoked by allergen exposure and confirmed by skin testing It may be required for confirmation of sensitivity to allergen in the work place
Standard radiographs
CT
MRI
Simple Ease Rapid performance Low cost High sensitivity / spesificity ( Prick test )
OME
U R T infection
Nasal polyp
AR Asthma
: 78 % : 71 %
Infectious : bacterial, viral, fungal Drug induced : aspirin & other medications Occupational rhinitis (allergy & non allergy) Hormonal : puberty, pregnancy, menstruation and hormonal disorders Other causes : foods, irritants, emotions, NARES Atrophic Rhinitis Idiopatic
Objectives :
relieving symptoms for improving QOL to avoid triggering factor to avoid / to treat complication
EDUCATION
Explain what is allergic rhinitis / reaction Explain the meaning of pos. allergic skin test Confirm whether there is correlation between allergen contact & rhinitis attack Explain how to do allergen avoidance
mites sources
pollen
weed
1.
ANTIHISTAMINE
Patient doesnt mind sedation effect It is not available Can not be afforded Classic antihistamine can be considered
Except :
Long acting more practical No sedating normal daily activity No / less cardiac effect Broad spectrum effects
3. INTRANASAL CORTICOSTEROID
Long term treatment safer than systemic application Effective to control AR symptoms
Note :
Patients should be well informed how to use Symptoms relieve is not directly achieved In some places it is unavailable
If inadequate control
If inadequate control
If resistent
If resistent
Nasal blockage
If persistent
Consider Immunotherapy
If inadequate control
Further examination & consider immunotherapy Or Surgical turbinate reduction