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Rinologi

Dr. M Nurman Hikmallah, SpTHT


SMF THT RSUD TRIPAT GERUNG
Lombok Barat
Sinus Paranasal

4 SINUS PARA NASAL


1. Sinus Frontal
2. Sinus Sphenoid
3. Sinus Ethmoid
4. Sinus Maksila
Fungsi sinus

Air conditioning
Keseimbangan kepala
Menjaga suhu
Resonansi

Fungsi normal sinus tergantung pd ventilasi


& drainase yg baik
Anatomi
Sinus
Sinus Maksila
Terbesar, piramid
Basis : dinding lateral rgg hidung
Apek : proc Zygomatikus
Sinus Maksila

Batas2 :
Anterior : permk fasial sinus maksila

Posterior : fosa infra temporal &

Pterigomaksila
Medial : dinding lateral hidung
Superior : dasar orbita

Inferior : proc alveolaris & palatum


Sinus maksila

Anatomi klinik

Dasar sinus dekat dengan


gigi PM 1 & 2
Batas superior dekat mata
Osteum sinus lebih tinggi
dari dasarnya
Diameter ostium 1-3mm
Sinus maksila
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
Sinus maksila

Vaskularisasi :
a. maksila interna

a. sphenopalatina

a. palatina mayor

a. alveolaris anterior - posterior


Sinus maksila

Histologi & fisiologi :


Mukosa : . lanjutan cavum nasi ( > tipis )
. epitel kolumner pseudo-
komplek bersilia
Sinus frontal

Sempurna usia > 8 tahun


Batas dengan orbita tipis
Muara di meatus medius
( bersama dg sinus maksila & sinus
ethmoid )
Sinus Ethmoid

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
Sinus Ethmoid

Batas batasnya
Lateral : Lamina papirasea ( mata)
Superior : Lamina kribosa
Posterior : Sinus sphenoid
Sinus Sphenoid
Letak : di dalam os sphenoid
Batas batas :
Superior : fosa cerebri media
Inferior : atap nasofaring
Lateral : sinus cavernosus &
a. carotis interna
Posterior : Pons / fosa cerebri
posterior
Komplek ostiomeatal

Celah sempit yg merupakan unit drainase


fungsional ta :
bula ethmoid,
prosesus uncinatus,
infundibulum ethmoid,
hiatus semilunaris,
ostium sinus maksila,
resesus frontalis
SINUSITIS

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

konsep one air one disease


SINUSITIS
Morbiditas tinggi
AS : 30 juta penderita ( 1989 )
90 % ke pelayanan primer
Indonesia :
data epidemiologik : ( - )

dx dasar konfirmasi : x foto

therapi tidak adekuat kronik


Pengetahuan Patogenesis
penting untuk :
Ketrampilan diagnosis sinusitis
Pemberian terapi tepat dan adekuat
Menurunkan :
Morbiditas

Angka absen

Lama sakit

Biaya pengobatan
PATOGENESIS

Dengan C.T. :
- Struktur sinus
- Kompleks ostiomeatal
Sinusitis disertai kelainan
kompleks ostiomeatal
Sinus sehat : bakteri aerob dan
anaerob dlm sinus
PATOGENESIS

- Kelainan/ obstruksi komplek


ostiomeatal
- Bakteri dalam rongga sinus
- Adanya faktor predisposisi

SIKLUS SINUSITIS
Faktor predisposisi

Berbagai kondisi yang mengarah pada obstruksi


sinus : infeksi & alergi
Berbagai variasi anatomis : septum deviasi,
konka bulosa, kKurvatura paradoksal konka
media
Gangguan klirens mukosilia : sindrom diskinesia
( Kartegener, silia imotil ), fibrosis kistik.
Imunosupresi atau imun defisiensi
SIKLUS SINUSITIS

Sekret kental
Sekret terbendung
Perubahan met. gas mukosa

Kongesti mukosa / obstruksi Silia & epitel rusak


anatomik hentikan aliran udara
dan drainase
Perbhn lingk. baik utk pertumb
bakteri di rgg tertutup
Ostium tertutup
Sekret yg tertimbun
Penebalan mukosa inflamasi jaringan
sumbatan lebih lanjut
Infeksi bakteri dalam
rongga sinus
Etiologi / penyebab sinusitis

Virus :
Corona virus, Rhinovrus, Influenza A, RSV
Bakteria aerob:
Streptokokus pnemoni,
H influenzae,
Moraxella catarhalis,
Streptokokus pyogenes,
Staphylokokus aureus
Bakteri anaerob
Diagnosis Sinusitis
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
Pemeriksaan fisik

Nyeri ketok daerah pipi / dahi


Rinoskopi anterior :
* mukosa hidung edem, hiperemi
* sekret mukopurulen kental
* warna kuning-kehijauan di kavum nasi dan
meatus medius
Pemeriksaan faring :
Drainase post nasal
Konfirmasi diagnosis

X foto sinus para nasal


Pungsi sinus
CT Scan

Cairan dalam sinus


Diagnosis Klinik sinusitis :
Kriteria Saphiro & Rachelefsky 1992

Mayor Minor
Rhinorhe purulen demam
Drainase post nasal nyeri kepala dan sinus
Batuk foetor

Sinusitis : 2 mayor
1 mayor + 2 / lebih minor
Task Forse AAOA dan ARS ( 1997)
Gejala mayor :
Sakit pada muka ( pipi, dahi,
hidung)
Buntu hidung Gejala minor :
Ingus purulen Batuk, demam ( yang akut )
Gangguan penciuman Nyeri kepala
pem hidung : ingus purulen Nyeri geraham
Halitosis
SINUSITIS ? Tenggorok berlendir

Dua gejala mayor atau lebih, atau


Satu gejala mayor disertai 2 gejala minor
PENGOBATAN

Sinusitis Akut
Antibiotika spektrum luas
Dosis cukup, 10-21 hari

Dekongestan hidung ( topikal/ sistemik )

Mukolitik
PENGOBATAN

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 RHINITIS :

Sign & symptoms :


Itching nose
Sneezing
Rhinorrhea
Nasal obstruction

Allergic salute
EPIDEMIOLOGY

Prevalence in ISAAC (Asher 1995) :


0.8 14.95 % in 6-7 years old
1.4 39.7 % in 13 14 years old
Low pervalence : Indonesia, Georgia, Greece
Semarang (2002) ISAAC phase 3, RA : 18,6%
High pervalence : Australia, UK and Latin Americ
In adults : no equivalent to ISAAC study
National survey : 5.9 % France and 29 % UK
WHO Classification of
Allergic rhinitis

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
SEVERITY OF THE DISEASE

1. MILD means no one of the following items


are present
Sleep disturbance
Impairment of daily activities / sport
Impairment of school / work
Troublesome symptoms
2. MODERATE SEVERE, when one or more
of the symptoms are present
MECHANISMS OF Allergic RHINITIS
Histamine Immediate rhinitis symptoms
Leukotrienes Itch, sneezing
Mast cell Prostaglandin's Watery discharge
Bradykinin,PAF Nasal congestion
IgE
allergen
B cell
IL4
Chronic ongoing rhinitis

Th2 cell eosinophils Nasal blockade


IL 3, 5, GMCSF Loss of smell
Nasal hyperreactivity
MAST CELL DEGRANULATION

allergen Y Y
Newly formed mediators
PLA2 AA + PAF

C.O 5 L.O

PGD2 LTC4 LTB


Preformed mediators LTD4
Histamine, Heparin, Tryptase,
LTE4
TNF , TGF , IL 3, 4, 5, 13
HISTAMINE EFFECTS
HISTAMINE
DEGRADATION
( histamine methyl transfera

H1-R
Nociceptive Nerves Vascular wall

CNS Endothelium
Itch. (Vascular Permeability)
Systemic Reflexes
Sneeze Vasodilatation
Allergic Salute
Parasympathic Reflexes
Serous/Mucous Secretion
Glandular Exocytosis
Diagram of DIAGNOSTIC PROCEDURES
(1)
patients with AR symptoms
( history of illness + physical exam.)

skin prick test

(+) (-)

eosinophil on
AR with AR without nasal cytology
complications / complication
concomitant dis
(+) (-)

NARES
allergic non allergic
Rhinitis ? rhinitis
Diagnostic Procedures (2)

1. Anamnesis
Chief complain :
1. Itching nose
2. Sneezing : morning >>
3. Serous nasal secretion
4. Nasal obstruction at night
Diagnostic Procedures (3)

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
Diagnostic Procedures

2. Physical examination
Should be performed with appropriate
lighting and use of nasal speculum

normal oedema
Diagnostic Procedures (5)
2. Physical examination
Including :
1. Nasal passage ways
2. Nasal mucosa
3. Turbinates
4. Secretion
5. Septum
6. Polyps ?
7. Sinusitis ?
Diagnostic Procedures (6)

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
Diagnostic Procedures (7)

4. Total serum Ig E
Neither very sensitive nor very specific
35 50 % AR Normal Ig E levels
Poor correlation with symptom and skin
testing result
Diagnostic Procedures (8)

5. Nasal provocation testing


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
Diagnostic Procedures (9)

6. Special diagnostic techniques


Upper airway endoscopy /
Rhinomanometry
Standard radiographs
CT
MRI
Diagnostic Procedures (10)

7. Testing for specific Ig E,


important for :
Determining whether patient has allergic
rhinitis
Identifying specific allergen for avoidance
measurement and allergen
immunotherapy
Diagnostic Procedures (11)

8. Skin testing to allergen :


Simple

Ease

Rapid performance

Low cost

High sensitivity / spesificity

( Prick test )
Allergy skin prick testing

Skin prick test :


positive result

wheal > 3mm diameter


A R and other diseases

OME

U R T infection
Allergic
Rhinitis Nasal
polyp
Bronkhial
Sinusitis
asthma
Comorbidity AR and Sinusitis

US : sinusitis 30 Mill / year (1989 )


sinusitis : 25 30 % AR
non sinusitis : 14 17 % AR
Sinusitis ( dx CT ) Newman at all 1994 :
AR : 78 %
Asthma : 71 %
Differential diagnosis of RA
Non allergic rhinitis :
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
Management of AR

Objectives :
relieving symptoms for improving QOL
to avoid triggering factor
to avoid / to treat complication
to change the natural history
Allergen elimination
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
Encourage to avoid the allergens
Globally important allergens

mites sources
mites pets : dogs

weed cockroaches
pollen
Pharmacological treatment
1. ANTIHISTAMINE
First line
Consider new antihistamine since :
Long acting more practical
No sedating normal daily activity
No / less cardiac effect
Broad spectrum effects
Except :
Patient doesnt mind sedation effect
It is not available
Can not be afforded
Classic antihistamine can be considered
2. NASAL DECONGESTANT
Indicated in patient with prominent nasal
obstruction complaint
As addition / combination with A H

Long term treatment


Systemic nasal decongestant, be careful
in hypertension cases and glaucoma.
Topical : rebound effect
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


Allergen Specific Immunotherapy
( ASIT )
ASIT : effective for treating allergic rhinitis
Recommended in patients with :
severe symptoms
failed by pharmacological treatment
positive correlation skin test & history
agree & well informed about duration, schedule
of injection & expected results
Intermittent AR : Adults & children
Is therapy needed ? If yes

Non-pharmacological therapy
Allergen avoidance measure

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/nasal AH or Nasal Nasal CS & oral/


cromon corticosteroids nasal AH

If inadequate Add further symptomatic


control treatment
Or
Short course oral CS
Or
Consider IT
Persistent AR : Adults Is therapy needed ? If yes

Non-pharmacological therapy
Allergen avoidance measure
Environment control

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/ nasal Nasal Nasal CS &


antihistamine corticosteroids Oral antihistamine

If inadequate
control If resistent
If resistent

Nasal blockage
Rhinorrhea
Antihistamine and
Oral / nasal Nasal ipratropium
decongestant bromide
Or
Short course oral
steroid If persistent
If inadequate control
Consider
Immunotherapy
Further examination &
consider immunotherapy
Or
Surgical turbinate reduction

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