MODUL 5.

2
MATERI THT-KL - 6
RINOLOGI 2
KELAINAN HIDUNG - INFEKSI

UNDIP UNIVERSITAS
DIPONEGORO
becomes an axcellent research university
 TOPIK BAHASAN
• Furunkel pada hidung (4A)
• Rinitis kronik (3A)
• Rinosinusitis akut (2)
• Rinosinusitis kronik (3A)
 STANDAR KOMPETENSI

Mahasiswa dapat ➔mengevaluasi kelainan

hidung baik ( infeksi akut dan kronik)
sehingga dapat mendesain upaya kesehatan
dalam melayani masyarakat berdasarkan etika
kedokteran
 KOMPETENSI DASAR
Mahasiswa mampu :
1. Menguasai anatomi, histologi, fisiologi hidung dan sinus paranasal.
2. mampu menjelaskan etiologi, predisposisi, patofisiologi dan
gambaran klinis infeksi hidung dan sinus paranasal
3. menentukan dan melakukan pemeriksaan penunjang (foto
rontgen, CT scan, MRI, nasoendoskopi)
4. Membuat diagnosis infeksi hidung dan sinus paranasal
5. Melaksanakan penatalaksanaan infeksi hidung dan sinus
paranasal: pemberian antibotik, keputusan penanganan tindakan,
menatalaksanaan komplikasi tindakan operatif
6. melakukan work-up, menentukan terapi dan memutuskan untuk
melakukan rujukan ke spesialis yang relevan.
 FURUNKEL HIDUNG (4A)
• Definisi
• Patofisiologi
• Diagnosis berdasarkan :
– Anamnesis
– Pemeriksaan fisik
– Pemeriksaan penunjang
• Terapi definitif secara mandiri dan lengkap
• Edukasi
INFEKSI HIDUNG LUAR
Lokasi : dorsum nasi.tip
Klinis : tanda radang +
SELULITIS
Kausa : Staph/Strepcoccus
Tx : Antibiotik

Lokasi: kel. sebasseus

folikel rambut
jar. subkutaneus
VESTIBULITIS / Tx : Analgetik
FURUNKOLOSIS AB topikal & sistemik
Kompres
Incisi
 RINOSINUSITIS (3A)
• Definisi
• Anatomi dan fisiologi sinus paranasal
• Patofisiologi
• Diagnosis berdasarkan :
– Anamnesis
– Pemeriksaan fisik
– Pemeriksaan penunjang
• Terapi
• Indikasi merujuk pasien
Sinus Paranasal
Sinus Frontal
Sinus Sphenoid
Sinus Ethmoid
Sinus Maksila
 Perkembangan Sinus
• Sinus maksila dan etmoid terbentuk sejak lahir
• Sinus frontal berkembang pada usia 5-6 tahun
• Sinus sfenoid berkembang pada usia 8-10 tahun

9
USIA PNEUMATISASI SINUS PARANASAL

(Naumann HH : H&N Surgery. WB Saunders, 1980)

FISIOLOGI SINUS
 Normal Sinus Health Cycle
Secretions stay fluid; contain
antibodies and IgA
Frontal
Soluble pollutants are sinuses
Mucous composition is
absorbed in the normal
mucosa
Ethmoid
sinuses

Particulate matter and Mucous secretion is

bacteria are removed by normal
mucociliary clearance

Maxillary
sinuses
Mucociliary flow prevents local OSTIUM IS OPEN
mucosal damage
Host defenses resist infection

Adapted from Kennedy DW, et al. Ann Otol Rhinol Laryngol Suppl. 1995;167:22-30.
KOMPLEKS OSTEOMEATAL

• KOM→ area di meatus medius yang

merupakan muara dari sinus etmoid
anterior, frontal and sinus maksila
• Etmoid posterior bermuara pada
meatus superior

• Ostiomeatal complex is the functional

relationship between the space and the ostia
that drain into it
13
 RINOSINUSITIS atau SINUSITIS ?

Rinitis sering bersama dengan sinusitis

• Sinusitis tanpa rinitis → JARANG
• Mukosa cavum nasi dan sinus
merupakan satu kesatuan
• Gejala hidung tersumbat dan ingus
kental merupakan gejala utama
sinusitis
 RINOSINUSITIS

• Inflamasi mukosa hidung dan sinus

→ infeksi dan non infeksi
• Morbiditas tinggi
AS : 30 juta penderita ( 1989 )
90 % ke pelayanan primer
 Rinosinusitis Cycle
Mucous thickens
Secretions stay fluid; contain
antibodies and IgA
Cilia and epithelium Frontal
sinuses Mucous secretion
Soluble
are pollutants
damage are Mucous composition
stagnate is
absorbed in the normal
mucosa
Ethmoid
Lack of drainage and thick sinuses
Particulate matter
mucus create and
culture Nasal
Mucous congestion
secretion is or
bacteria
mediumare removed
growth by
in closed anatomic obstruction
normal
mucociliary clearance blocks air flow and
drainage

Retained mucus secretions Maxillary

sinuses OSTIUM
cause tissue inflamation
Mucociliary flow prevents local OSTIUMISISCLOSED
OPEN
mucosal damage
Bacterial infection Mucosal thickening creates
develops
Host in resist
defenses the sinus further blockage
infection cavity

Adapted from Kennedy DW, et al. Ann Otol Rhinol Laryngol Suppl. 1995;167:22-30.
Sinus and Allergy Health Partnership (SAHP). Otolaryngol Head Neck Surg. 2000;123:S1-S32.
PREDISPOSING FACTORS
 Septal Deviation Can Impinge
on Ostiomeatal Region

F. Netter: Collection of Ciba Geigy - 1989

Allergies Cause Mucosal Edema, Resulting in Inflammation,
& Turbinate Hypertrophy with Polypoid Degeneration

Enlarged, Polypoid Turbinates

Edematous, Inflammed
Mucosa Sealing Hiatus
Semilunaris

Kennedy D: Otolaryngol Head Neck Surg 103:851, 1990

 Rhinosinusitis Versus Inhalant Allergy
Infection Allergy
– Nasal obstruction / – Nasal obstruction / congestion
congestion – Thin, watery discharge
– Thick nasal discharge – Paroxysmal sneezing
– Cough / irritability – Pruritic nose / palate, may have
– Pressure with pain, & headache from barosinusitis
may have headache or – Frequently Seasonal (can
toothache increase incidence of sinusitis)
– Fever (usually minor) – Other allergic Sxs
– Other infection Sxs (conjunctivitis, laryngitis,
(pharyngitis, otitis) asthma, ET dysfunction)
 KLASIFIKASI RINOSINUSITIS

? Apakah rinosinusitis akutViral

Akut
viral atau bakterial?
Bakterial
Subakut
RINOSINUSITIS
Akut berulang

Kronik

Kronik eksaserbasi akut

Lanza D, Kennedy D. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg
1997;117(suppl):S1.
Causes of Rhinosinusitis – Time Course
Viral

Aerobes
Resistant Aerobes,
Anaerobes & Fungi

7–10 Days 3 Months

 RINOSINUSITIS AKUT

VIRAL BAKTERIAL

• DEFINISI : Rinosinusitis yang berlangsung < 12 minggu

• KLASIFIKASI :
A. Rinosinusitis akut viral → gejala < 10 hari
B. Rinosinusitis akut non viral →bila gejala tidak membaik
dalam 10 hari atau memburuk setelah 5-7 hari

1
Gwaltney Clin Infect Dis 1996;23:1209
2
Berg et al. Rhinology 1986;24:223-5
 PATHOGENESIS OF A RHINOVIRUS “COLD”
Virus Infection of Nasal Epithelium

Proinflammatory
cytokines Neurogenic Tracheobronchial
(IL-1, -6, -8) responses infection

Secondary Cholinergic stimulation

inflammation
(PMNs, kinins)
Vasodilation Mucus Airway
Serum transudation secretion hyperreactivity

Nasal
Sore Throat Sneezing Obstruction Rhinorrhea Cough
 MOST PREVALENT PATHOGENS
IN ADULT SINUSITIS
Other (4%)
Staphylococcus aureus
(0-8%)
Moraxella catarrhalis Streptococcus
(2-10%) pneumoniae (20-43%)

Anaerobes (0-9%)

Streptococcus spp.
(3-9%)

Haemophilus influenzae
1. Sinus and Allergy Partnership. Otolaryngol Head Neck Surg 2004. (22-35%)
2. AAOHNS. Otolaryngol Head Neck Surg. 2007.
 GEJALA
MAYOR RACHELEFSKY
SAPHIRO &MINOR
• Rhinorhe purulen • Demam
• Drainase post nasal • Nyeri kepala & sinus
• Batuk • Foetor

MAYOR TASK FORCE AAOA

MINOR
DAN ARS
• Nyeri wajah • Batuk,
• Buntu hidung • Demam (akut)
• Ingus purulen • Nyeri kepala
• Gangguan penciuman • Nyeri geraham
• Ingus purulen • Halitosis
• Post nasal drip
 GEJALA
MAYOR EPOS 2012
MINOR

• Nasal • Facial pain/pressure

obstruction/blockage/c
• Reduction/loss of
ongestion
smell (adult)
• Nasal discharge
• Cough (children)
(anterior / posterior
nasal drip)

European Position paper on Rhinosinusitis and nasal

polyps (EPOS) 2012, by International Rhinologic Society
SINUS HEADACHE

Page 1
 PEMERIKSAAN FISIK
• Nyeri ketok daerah pipi / dahi
• Rinoskopi anterior :
* mukosa udem, hiperemis
* sekret mukopurulen kental
* warna kuning-kehijauan di kavum
nasi dan
meatus medius
• Pemeriksaan faring :
Drainase post nasal
SINUS TRANSILLUMINATION

• Have patient sit at your eye level in

darkened room (the darker the better)
• Let eyes get accustomed to dark
• Place bright light (transilluminator) over I nferior orbital
ridge to look at maxillary sinuses, under superior orbital
rim for frontal sinuses
• Look at palate for presence/absence of transilluminated
light

32
PEMERIKSAAN PENUNJANG
• X – foto sinus para nasal
• Pungsi sinus
• CT – Scan
 PEMERIKSAAN RADIOLOGI
X Foto SPN →Occipitomental, Occipitofrontal, Axial,
Lateral bitemporal, Rhese’s oblique

WATERS CALDWELL
CT Scan SPN

Polip sinus maksila

Ethmoiditis dan sfenoiditis

 D
I
A
PEMERIKSAAN G
PENUNJANG N
PEMERIKSAAN O
FISIK S
I
S
ANAMNESIS
 DIAGNOSIS
AKUT
WAKTU
KRONIK
FRONTAL
ETHMOID
LOKASI
MAKSILA
SFENOID

MULTISINUSITIS
JUMLAH SINUS
PANSINUSITIS
 TERAPI
• Antibiotik TUJUAN TERAPI RSA
• Antiinflamasi •Mempercepat penyembuhan
• Antihistamin •Menghindari kronisitas
• Dekongestan •Mengurangi kekambuhan asma/
• penyakit lain
Mukolitik
• Nasal irigasi INDIKASI RAWAT INAP:
•Keadaan akut dengan demam dan
G
nyeri kepala berat
A
G •Susp sphenoiditis
A
Operatif
•Dengan komplikasi
L
 KOMPLIKASI
• Terjadi perluasan infeksi di mukosa yang melibatkan
tulang dan struktur disekitarnya

AKUT
KLASIFIKASI
KRONIK

Lokal (locoregional)
LOKASI
Jauh (distant)
 KOMPLIKASI LOKAL
Mata
Tulang
EKSTRAKRANIAL
Telinga
Tenggorok

Subdural empyema
INTRAKRANIAL Epidural abscess
Cerebral abscess
 KOMPLIKASI LOKAL
• Granulasi faring
• Tonsillitis kronik
• Laringitis
• Otitis media efusi
OSTEOMYELITIS….
• Frontal Bone
– Dangerous and more extensive.
– Dull local pain and swelling of the upper eye lid.
– Potts puffy tumor
– High risk if intracranial complications
• Treatment
– IV ABs and debridement
 KOMPLIKASI ORBITA
Sinus
etmoid

Selulitis orbita

Hubungan sinus terhadap orbita

 INTRA CRANIAL COMPLICATIONS
Complications arise form
Frontal
Etmoid
Sphenoid
Mode of Spread
Direct
Retrograde thrombophlebitis
Meningitis- commonest
Intracranial abscess
Sinus
Extradural
frontal Subdural
Cerebral
Encephalitis
Sinus Cavernous sinus thrombophlebitis
ethmoi
d A. Subdural empiema
Sinus B. Abses serebri
sfenoid C. Meningitis
D. Trombosis sinus sagitalis superior
 PENATALAKSANAAN
• Diagnosis by clinical presentation
• Thight Evaluate for complications
• Admit to hospital
• Treat high dose AB ,anti inflamation
• Do the surgery
• Work up &Consult to opthalmic and neuro surgeon
 Summary
• Acute rhinosinusitis is usually related to
infection
– Antibiotic management is first line
• Chronic rhinosinusitis is usually related to
inflammation
– Further characterization of the condition is important
(nasal polyps)
– Exploration of underlying allergy is important
– Management is challenging
? ? ?
 RINITIS KRONIK (3A)
• Definisi
• Patofisiologi
• Diagnosis berdasarkan :
– Anamnesis
– Pemeriksaan fisik
– Pemeriksaan penunjang
• Terapi
• Indikasi merujuk pasien
 RINITIS

Akut
Kronik
INFEKSI
Spesifik
Non Spesifik
 Rhinitis chronica
RINITIS KRONIK NON SPESIFIK Atrophicanscum foetida
Ozaenae
Dry rinitis
Rare and progressive cases Rhinitis sicca
Prevalens → P : L = 3 : 1 Open-nose syndrome
Mostly on puberty age
Endemic in tropical areas with hot climates and in
developing countries

PRIMARY
• Endocrine 
SECONDARY
• Vascular disorders 
• Surgery 
• Nutrition 
• Trauma
• Anatomy
• Radiation therapy
• Autoimmune infection
• Genetic
 RINITIS ATROFI
SYMPTOMS :
Nasal obstruction ; disruption of air flow
Headache
Epistaxis ; pell of crusting
Anosmia ; atrophy of the olfactory mucosa
Bad smell from the nose
Throat discomfort

PHYSICAL EXAMINATION :
Foetor nasi
Green, yellow or black crusting ;
sometimes difficult to removed
Konka media and inferior atrophy
Faringitis sicca
 RINITIS ATROFI
ADVANCE EXAMINATION :
Transillumination
Microbiology : Culture and sensitivity test
Histopatology
Radiology : CT Scan SPN
RINITIS ATROFI
THERAPY
• Nasal cavity irrigation ; normal saline
• Nasal drop lubrication ; 2% menthol in parafin
• Intranasal tamponade ; 24hour, 25% glucose in glycerin
→ inhibit proteolytic organisms and soften the crust
• Antibiotics ; according to culture sensitivity initial therapy :
→streptomycin, rifampicin or ciprofloxacin
• High dose vit A ;
(12.500 to 15.000 IU each day/2 weeks)
• Iron preparation
 RINITIS TUBERKULOSA
• Jarang
• Causa : Mikobakterium Tuberculosa
• Bisa primer atau sekunder
• GEJALA : Nyeri, Obstruksi, Sekret mukopurulen
• TANDA :
• Nodul merah terang dg /tanpa ulserasi
• Lesi : Nodul/ulserasi pd septum, konka
media/inferior
• PEMERIKSAAN PENUNJANG : Bakteriologi, biopsi

• TERAPI: OAT ekstrapulmoner & Nose toilet

 RINITIS SIFILIS / LUETIKA
• Causa : Treponema Pallidum
• Khas : edem, end arteritis pd lumen menyempit, nekrosis &
ulserasi
PRIMER : lesi di vestibulum & hidung luar, papul dg ulkus yg
keras,tidak sakit (3-4mgg stlh kontak) ,hilang spontan (6-10
mgg)
Test serologi + /-
SEKUNDER: >> 10 mgg
Sangat infeksius (mirip R.Simplek)
Sulit didiagnosa ,kec, ada lesi lain
Test serologi +++
TERSIER khas Gumma
Merusak perios,tulang : sadle nose
• Terapi : PPO
RINITIS LEPROMATOSA
• Granulomatosa spesifik
• Causa : Mikobakterium leprae
• Inkubasi s/d 10 tahun
Erytematous
• Tanda klinis : SaddleDiffuse plaque
nose infiltration, crust,
Hypocromic
• General = tanda morbus hansen (madarosis, spot spots
MADAROSIS dry mucosa
hipokromik, plak eritematosus) saddle nose
• Rinoskopi anterior : mukosa hiperemis, dry mukosa, krusta

•Pemeriksaan penunjang: laboratorik (kuman M. Leprae +) dan

histopatologi
• Terapi anti lepra : Diapsone,rifampicin
 PERTANYAAN
1. Jelaskan perbedaan furunkel dengan selulitis
nasi!
2. Apa tanda patognomonis rinitis atrofi?
3. Bagaimana cara menegakkan diagnosis rinitis
spesifik?
4. Apa faktor predisposisi terjadinya sinusitis
maksilaris?
5. Apa penyebab komplikasi orbita pada
rinosinusitis?
TERIMA KASIH