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Understanding of Rhinosinusitis

: complication and implication


of Rhinosinusitis daily practice
Oleh :
dr. Gusti Ayu Trisna Aryani Sp.THT
External Nose
Pyramidal in shape with its root up
and the base downwards1

Consists of osteo-cartilaginous
framework covered by muscles and
skin1
Upper 1/3rd bony and lower 2/3rd
cartilaginous

Shape and appearance of the


external nose affects both
appearance of the face and
functional processes that take place
inside the nose2
1
External Nose. In: Dhingra PL. ed. Diseases of ear nose and throat. New Delhi. ELSEVIER.129-132
2
Diseases of the Nose, Paranasal Sinuses, and Face. In: Probst R, ed. Basic Otorhinolaryngology. New
York. Thieme.2006. 1 - 7
Nasal Cavity
Begin anteriorly at the nasal
vestibule
Nasal septum divides the
nasal cavity into two
Boundaries of nasal cavity
Lateral: lateral nasal wall
Superior: cribriform plate
Floor: hard palate
Several functionally
important structures are
located on the lateral nasal
wall

1
Diseases of the Nose, Paranasal Sinuses, and Face. In: Probst R, ed. Basic Otorhinolaryngology. New
York. Thieme.2006. 1 - 7
Nasal Mucosa in Various Parts of the
Nasal Cavity
Olfactory region
Upper 1/3rd of lateral wall (up to
superior concha), corresponding
part of the nasal septum and the
roof of nasal cavity form the
olfactory region
Mucous membrane is paler in
Respiratory
colour region
Lower 2/3rd of nasal cavity
Mucous membrane shows
variable thickness
Lined by pseudostratified
ciliated columnar epithelium
Serous and mucous, glands are
located in the submucosa

1
External Nose. In: Dhingra PL. ed. Diseases of ear nose and throat. New Delhi. ELSEVIER.129-132
Paranasal Sinuses
Air-filled cavities that communicate
with the nasal cavities

4 types of paranasal sinuses

Anatomical connections between


the nasal cavity and paranasal
sinuses are functionally important
and play a key role in the
pathogenesis of many rhinologic
diseases
1
Diseases of the Nose, Paranasal Sinuses, and Face. In: Probst R, ed. Basic Otorhinolaryngology. New
York. Thieme.2006. 1 - 7
Ostiomeatal Unit and its
Significance
Area on the lateral nasal wall where the
Ostia of the paranasal sinuses open into
the nasal cavity in a duct-like fashion
Even minor changes can hamper
ventilation in this region
Leads to pathologic squeal in the
paranasal sinuses
Main clinical significance of this region
relates to the sites of narrowing in the
ostiomeatal unit
Hyperemia and swelling of the mucosa
in the setting of a common cold can
obstruct the narrow passages in the
ostiomeatal unit
Prevents adequate ventilation of the
dependent paranasal sinus system and
1
Diseases ofsetting
the Nose,the stageSinuses,
Paranasal for a rhinogenic
and Face. In: Probst R, ed. Basic Otorhinolaryngology. New York.
Thieme.2006. inflammation
1-7 of the paranasal sinuses
Mucociliary Action
Mucociliary apparatus physically
cleanses the inspired air
Consists of the cilia of the respiratory
epithelium and a mucous blanket
composed of two layers
Disturbances in mucociliary transport
Increased viscosity and thickness of the
sol layer
Changes in the viscoelasticity of the gel
layer
Acute viral infection
Rhinitis
Inflammation of the nasal Classification based on
duration of disease2
mucosa1

Associated with excessive Rhinitis2

mucus production,
congestion, sneezing Chronic
Acute rhinitis rhinitis
paroxysm, watery eyes, < 4 days/ > 4 days/week
and nasal and ocular week or < 4
weeks duration
or
> 4 weeks
pruritus.1 duration
1
Quillen DM, Feller DB. Diagnosing Rhinitis: Allergic
vs. Nonallergic. Am Fam Physician. 2006;
73(9):1583-1590
2
Kradjan W. Acute and Chronic Rhinitis. Dr Ted
Williams.
RINOSINUSITIS
Rinosinusitis (termasuk polip hidung) didefinisikan sebagai :
inflamasi hidung dan sinus paranasal yang ditandai dengan adanya dua atau lebih
gejala, salah satunya : Hidung tersumbat/ obstruksi/ kongesti atau pilek (sekret hidung
anterior/ posterior):
nyeri wajah/ rasa tertekan di wajah
penurunan/ hilangnya penghidu

dan salah satu dari temuan nasoendoskopi:


polip dan/ atau
sekret mukopurulen dari meatus medius dan/ atau
edema/ obstruksi mukosa di meatus medius

- Dan/ atau pada gambaran tomografi komputer:


- perubahan mukosa di kompleks osteomeatal dan/atau sinus
Acute Rhinosinusitis (ARS)
Sudden onset of 2 or more symptoms of nasal discharge, nasal
blockage or congestion, facial pain or pressure and reduction or
loss of sense of smell, which are < 12weeks in duration. 1

Etiology 2
Signs and symptoms 1

Viral upper respiratory infection Lowgrade fever


Nasal polyps Malaise
Mucociliary dysfunction Headache
associated with cystic fibrosis Cough
immune deficiencies Bilateral nasal mucosal oedema
Purulent nasal secretions
Sinus tenderness
Toothache
Periorbital swelling
1
Masood A, Moumoulidis I, Panesar J. Acute
rhinosinusitis in adults: an update on current
management. Postgrad Med J. 2007; 83(980): 402
408.
2
Osguthorpe JD. Adult rhinosinusitis: Diagnosis and
Acute Rhinosinusitis (ARS)
Inflammation of the nasal mucosa and lining of the
paranasal sinuses
Obstruction of sinus ostia
Impaired ciliary transport
Viral etiology in majority of cases
Superimposed bacterial infection in 0.5-2%
Symptoms for at least 7-10 days or worsening after 5-7 days
Symptoms present for < 4 weeks
Recurrent ARS with > 4 episodes, lasting > 7-10days
NOTES: Most viral upper respiratory tract infections are caused by
rhinovirus, but coronavirus, influenza A and B, parainfluenza, respiratory
syncytial virus, adenovirus, and enterovirus are also causative agents.
Acute Rhinosinusitis (ARS)
Major symptoms
Facial pain/pressure Hyposmia/anosmia
Facial congestion/fullness Purulence on exam
Nasal obstruction Fever (ARS only)
Nasal discharge/purulence
Minor symptoms
Headache
Dental pain
Fever (non-ARS)
Halitosis Cough
Fatigue Ear pain/pressure/fullness
Diagnosis with two major or one
major and two minor factors
Treatment and Complications
Complications3
Treatment Acute ear Most common in
infection children
Pain relievers Wheezing seen in children with
asthma
like
Sinusitis Inflammation and
Acetaminophen1 infection of the
Decongestant sinuses in adults or
children
nasal
Other Streptococcal
sprays/drops secondar pharyngitis,
may help relieve y pneumonia,
a blocked Diseases
nose 2 infections bronchiolitis in
1
and conditions common cold. Mayochildren
Cough syrups
clinic. http://www.mayoclinic.org/diseases-
conditions/common-cold/basics/treatment/con-
20019062. 2013. Accessed Aug 18, 2015.
2
Common cold Treatment. NHS choices.
http://www.nhs.uk/conditions/cold-
common/pages/treatment.aspx. 2015. Accessed
Chronic Rhinosinusitis (CRS)
Symptoms present for > 12
consecutive weeks
Subacute for symptoms between 4-
12 weeks
Chronic inflammation
Bacterial, fungal, and viral
Allergic and immunologic
Anatomic
Genetic
NOTES:
predisposition
One of the major problems with identifying the pathogenesis of CRS is that neither symptoms, findings, nor
radiographs, taken independently, are sufficient basis for the diagnosis. One study showed that current symptom-
based
No clear consensus on
criteria had only a 47% correlation with a positive CT scan result.
Stankiewicz JA, Chow JM: A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity. Am J
pathophysiology
Rhinol 2002; 16:199-202.
Sinusitis Pathophysiology2
Inflammation of sinus paranasal
(-es)
Characterised by nasal Ostial obstruction
congestion, facial pressure,
cough and thick nasal discharge
Oxygen tension is
It is of two types based on impaired
duration of illness
Acute Sinusitis Ciliary activity is
Symptoms lasting < 4 weeks reduced
Starts as common cold and
symptoms often go away within a
week to 10 days
Chronic Sinusitis Stasis of secretions
Often diagnosed when symptoms
have gone on for >12 weeks.
People with allergic rhinitis or Saprophyte infection
asthma are more1Sinusitis.
likely toAmerican
suffer Academy of Allergy Asthma
from chronic sinusitis
and Immunology. http://www.aaaai.org/conditions-
and-treatments/allergies/sinusitis.aspx. 2015.
Accessed. August 18,2015. 2 Suh KS. Functions of
paranasal sinuses.
Symptoms, Diagnosis and
Management of Sinusitis
Symptoms Allergy Testing

Diagno
Painful pressure in the cheeks and forehead
Thick yellow-green nasal discharge
Postnasal drip, often with a bad taste
Examination of nasal
Cough passages - Rhinoscopy or

sis
Congestion Nasal endoscopy
Toothache MRI or CT scan
Fever

Acute Sinusitis Management Chronic Sinusitis Management

Recover without any prescribed Intranasal corticosteroid sprays may


medications be appropriate for recurrent sinusitis
Oral Decongestants or nasal Treating allergies by avoiding triggers
decongestant sprays might help or with medications or allergy shots
relieve symptoms and promote can help prevent recurrences of
drainage of the infection sinusitis.
Sinus saline recipe may relieve Endoscopic sinus surgery may be
symptoms. considered when medical treatment
Pain relievers such as acetyl salicylic fails
acid, acetaminophen or ibuprofen
1
Sinusitis.
may be American Academy of Allergy Asthma and Immunology. http://www.aaaai.org/conditions-
beneficial
and-treatments/allergies/sinusitis.aspx. 2015. Accessed. August 18,2015
Nasal Decongestants
Nasal Congestion(NC)
Described as fullness, obstruction,
reduced airflow, or being stuffed Pathophysiology2
up,1
Mucosal inflammation
is the central
NC has not been extensively studied. mechanism that
1
contribute to
Allergic Rhinitis(AR) is the common congestion
cause for NC.
Inflammation induces
Burden of NC can be indirectly
estimated based on AR burden the vasodilatation,
increased blood flow
and vascular
Global incidence of AR is estimated permeability
as 10- 20% 1
This
Stewart M, Ferguson BJ, Fromer
1
reduce the
L. Epidemiology
and burden of nasal congestion. International
physical
Journal of General Medicine .2010; 3:3745 size of the
nasal passages
Naclerio RM, Bachert C, Baraniuk JN.
2
Diseases causing NC and Quality of
Life (QOL)
Allergic Rhinitis Rhinosinusitis Nasal polyposis(NP)

10-20% globally 66-70% NC is one of the


Study on 111 Rhinosinusitis severe symptom
patients with have NC in NP
moderate-to- Significant 2-4% of
severe perennial decrease in QOL prevalence
AR reported globally
significantly lower
scores of QOL
Impairment in
physical
limitations, pain,
social functioning,
general health
perception,
Economic burden for the
energy/fatigue treatment of associated disease of NC is
also very high
1
Stewart M, Ferguson BJ, Fromer L. Epidemiology and burden of nasal congestion. International
Journal of General Medicine .2010; 3:3745
Adrenergic Receptors
Classified into 2 types Adrener
based on affinities of gic
adrenergic agonists. receptor
Nasal decongestants acts
s
on and receptors and
decrease nasal congestion
Selective 1 and 2
agonists, -Adrenergic
agonist are common
nasal decongestants drug
class
1, 2,
1, 2
3
1
Tripathi KD. Essentials of Medical Pharmacology.
New Delhi: Jaypee Brothers Medical
Publishers;c2013:125-137
Classification of Nasal
Decongestants
-
selective Selective
Adrenergi
1 agonist 2 agonist
c Agonist

Phenylephrine Naphazoline Pseudoephedrine

Phenylpropanola
Oxymetazoline Xylometazoline
mine

Oxymetazoline

1
Tripathi KD. Essentials of Medical Pharmacology.
New Delhi: Jaypee Brothers Medical
Publishers;c2013:125-137
Overview of Nasal Decongestants
Naphazoline Xylometazolin Oxymetazol Pseudoephedr Phenylpropanola
e ine ine mine
Mode of Selective 2 Selective 2 Selective 2 Alpha- Directly stimulate
action agonist) agonist) agonist) Adrenergic adrenergic
Agonist. receptors but
probably indirectly
stimulates both -
and -adrenergic
receptors
Duration Longer duration Longer duration Long
of action of action (12 of action (10 duration of
hours) hours)2 action (12
hours)
Dose 0.1% topical in 0.050.1% 0.0250.05% 30- 60 mg three 2550 mg daily
nose topical in nose topical in times a day
nose
Adverse Impairs mucosal Impairs Impairs Rise in BP can Rise in BP
effects ciliary function mucosal ciliary mucosal occur,
causing Atrophic function ciliary especially in
rhinitis and causing function hypertensive,
anosmia, CNS Atrophic rhinitis causing CNS effects
depression and and anosmia, Atrophic
rise in BP, initial CNS depression rhinitis and
1
Tripathi KD. Essentials of Medical Pharmacology.
stinging and rise in BP anosmia,
New Delhi:Jaypee Brothers Medical
sensation CNS
Publishers;c2013:125-137. depression
2
SUDAFED 0.1% NASAL
SPRAY. MHRA. and rise in
http://www.mhra.gov.uk/home/groups/par/docume
BP
Nasal Decongestants
Two main types are used:
Adrenergics (largest group)
Constrict dilated blood vessels
Nasal mucosa
Corticosteroids
Reduce inflammation

Copyright 2007 Thomson Delmar


Learning, a division of Thomson
Learning Inc. All rights reserved.
Goal of Nasal Decongestants
To reduce congestion
Two dosage forms
Oral
Topical
Nasal spray

Copyright 2007 Thomson Delmar


Learning, a division of Thomson
Learning Inc. All rights reserved.
Oral Decongestants
Prolonged effects
Less potent
No rebound congestion
Exclusively adrenergics
Example: pseudoephedrine (Sudafed)

Copyright 2007 Thomson Delmar


Learning, a division of Thomson
Learning Inc. All rights reserved.
Topical Decongestants
Adrenergics
Prompt onset
Sustained userebound congestion
Both adrenergics and steroids
Potent; work well

Copyright 2007 Thomson Delmar


Learning, a division of Thomson
Learning Inc. All rights reserved.