Sinusitis: Fakhri Mubarok 1510211033

SINUSITIS Fakhri Mubarok 1510211033

SINUSITIS 

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Inflamasi mukosa sinus paranasal Umumnya dipicu o/ rinitis → rinosinusitis Penyebab utama: selesma (common cold) Istilah:  

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Multisinusitis Pansinusitis

Paling sering terkena: 

Sinus etmoid dan maksila

ETIOLOGI Nasal infections. Sinus mucosa is a continuation of nasal mucosa and infections from nose can travel directly by continuity or by way of submucosal lymphatics. Most common cause of acute sinusitis is viral rhinitis followed by bacterial invasion.

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Trauma. Compound fractures or penetrating injuries of sinuses—frontal, maxillary and ethmoid—may permit direct infection of sinus mucosa. Dental infections. This applies to maxillary sinus. Infection from the molar or premolar teeth or their extraction may be followed by acute sinusitis.

Gray's Anatomy The Anatomical Basis of Clinical Practice, 40th Ed ; hal 519

FAKTOR PREDISPOSISI 

LOCAL 

Obstruction to sinus ventilation and drainage. Normally, sinuses are well-ventilated. They also secrete small amount of mucus, which by ciliary movement, is directed towards the sinus ostia from where it drains into the nasal cavity. Any factor(s) which interfere with this function can cause sinusitis due to stasis of secretions in the sinus. They are: a) b) c) d) e)

Deviated septum Hypertrophic turbinates Oedema of sinus ostia due to allergy or vasomotor rhinitis Nasal polypi Benign or malignant neoplasm.

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Stasis of secretions in the nasal cavity. Normal secretions of nose may not drain into the nasopharynx because of their viscosity (cystic fibrosis) or obstruction (enlarged adenoids, choanal atresia) and get infected. Previous attacks of sinusitis. Local defences of sinus mucosa are already damaged.

GENERAL 

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Environment. Sinusitis is common in cold and wet climate. Atmospheric pollution, smoke, dust and overcrowding also predispose to sinus infection. Poor general health. Recent attack of exanthematous fever (measles, chickenpox, whooping cough), nutritional deficiencies and systemic disorders (diabetes, immune deficiency syndromes). Swimming and diving. Infected water can enter the sinuses through their ostia. High content of chlorine gas in swimming pools can also set up chemical inflammation.

EPIDEMIOLOGI 

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Paling banyak ditemukan di seluruh dunia, terutama di daerah yg berpolusi tinggi Iklim yg lembab, dingin, dgn konsentrasi pollen yg tinggi Sinus maksila → insidensi terbesar Perempuan lbh banyak memiliki episode sinusitis akut drpd pria

Sekret menjadi purulen

PATOFISIOLOGI Bakteri menginvasi nasofaring Faktor kemotaktik Inflamasi akut mukosa sinus Pelepasan mediator2 kimiawi Histamin

Bradikinin

Media yg baik u/ pertumbuhan bakteri Transudasi serosa Terjadi tekanan negatif dlm rongga sinus

Prostaglandin

Demam

Vasodilatasi Hiperemi

Multiplikasi bakteri

Permeabilitas kapiler meningkat

Edema

Silia tidak dapat bergerak

Ostium tersumbat

Mukosa yg berhadapan akan saling bertemu

KLASIFIKASI DAN MIKROBIOLOGI 

Sinusitis Akut >

4 minggu  Bakteri utama:  Streptococcu

pneumoniae  Haemophyllus inflenzae  Moraxella catarrhalis 

Sinusitis Subakut 4

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minggu – 3 bulan

Sinusitis Kronis >

3 bulan

GEJALA KLINIS DAN PENGOBATAN 

Keluhan utama :  Hidung

tersumbat disertai nyeri/rasa tekanan pd muka dan ingus purulen yg sering kali turun ke tenggorok (post nasal drip)  Gejala sistemik → demam & lesu 

Gejala lain :  Sakit

kepala  Hiposmia/anosmia  Halitosis  Post nasal drip

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Sinusitis Maksila Akut Clinical features depend on (i) severity of inflammatory process and (ii) efficiency of ostium to drain the exudates.  Closed ostium sinusitis is of greater severity and leads more often to complications. 

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Constitutional symptoms. It consist of fever, general malaise and body ache. They are the result of toxaemia. Headache. Usually, this is confined to forehead and may thus be confused with frontal sinusitis. Pain. Typically, it is situated over the upper jaw, but may be referred to the gums or teeth. For this reason patient may primarily consult a dentist. Pain is aggravated by stooping, coughing or chewing. Occasionally, pain is referred to the ipsilateral supraorbital region and thus may simulate frontal sinus infection.

 Redness

and oedema of cheek. Commonly seen in children. The lower eyelid may become puffy.  Nasal discharge. Anterior rhinoscopy/nasal endoscopy shows pus or mucopus in the middle meatus. Mucosa of the middle meatus and turbinate may appear red and swollen.  Postnasal discharge. Pus may be seen on the upper soft palate on posterior rhinoscopy or nasal endoscopy.

TREATMENT 

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Antimicrobial drugs. Ampicillin and amoxicillin are quite effective and cover a wide range of organisms. Erythromycin or doxycycline or cotrimoxazole are equally effective and can be given to those who are sensitive to penicillin. Nasal decongestant drops. One per cent ephedrine or 0.1% xylo- or oxymetazoline are used as nasal drops or sprays to decongest sinus ostium and encourage drainage.

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Steam inhalation. Steam alone or medicated with menthol or Tr. Benzoin Co. provides symptomatic relief and encourages sinus drainage. Inhalation should be given 15–20 min after nasal decongestion for better penetration. Analgesics. Paracetamol or any other suitable analgesic should be given for relief of pain and headache. Hot fomentation. Local heat to the affected sinus is often soothing and helps in the resolution of inflammation

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Sinusitis Frontal Akut  Frontal

headache. Usually severe and localized over the affected sinus. It shows characteristic periodicity.  Oedema of upper eyelid with suffused conjunctiva and photophobia.  Nasal discharge. A vertical streak of mucopus is seen high up in the anterior part of the middle meatus.  Nyeri pd dahi/seluruh kepala

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Sinusitis Etmoid Akut 

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Acute ethmoiditis is often associated with infection of other sinuses. Ethmoid sinuses are more often involved in infants and young children.

CLINICAL FEATURES  

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Pain. It is localized over the bridge of the nose, medial and deep to the eye. It is aggravated by movements of them eye ball. Oedema of lids. Both eyelids become puffy and swollen. There is increased lacrimation. Orbital cellulitis is an early complication in such cases. Nasal discharge. On anterior rhinoscopy, pus may be seen in middle or superior meatus depending on the involvement of anterior or posterior group of ethmoid sinuses. Swelling of the middle turbinate.

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Sinusitis Sfenoid Akut  Biasanya

jarang; berhubungan dgn sinusitis etmoid

podterior  Gambaran Klinis:  Nyeri

→dirasakan pd verteks, oksipital, belakang bola mata, dan daerah mastoid  Pos nasal discharge → hanya dapat dilihat pd rhinoskopi posterior → pus dpt dilihat dr atap posterior nasofaring dan konka

DIAGNOSIS  

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Berdasarkan anamnesis, px fisik, dan px penunjang Px fisik dgn rinoskopi anterior dan posterior, px naso-endoskopi → sangat dianjurkan Tanda khas  Adanya

pus pd meatus medius → sinusitis maksila, etmoid anterior, dan frontal  Adanya pus pd meatus superior → sinusitis etmoid posterior dan sfenoid

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Px penunjang:  Foto

polos → posisi Waters, PA, dan lateral → umumnya hanya mampu menilai kondisi sinus2 besar  CT-scan  Px Transiluminasi  Px Mikrobiologi dan Tes Resistensi  Sinoskopi  Dilakukan dgn

pungsi menembus dinding medial sinus maksila melalui meatus inferior  Dgn alat endoskop  Selanjutnya, dapat dilakukan irigasi sinus u/ terapi

Gray's Anatomy The Anatomical Basis of Clinical Practice, 40th Ed ; hal 550

Gray's Anatomy The Anatomical Basis of Clinical Practice, 40th Ed ; hal 551

Gray's Anatomy The Anatomical Basis of Clinical Practice, 40th Ed ; hal 551

Gray's Anatomy The Anatomica l Basis of Clinical Practice, 40th Ed ; hal 551

TERAPI 

Tujuan: Mempercepat penyembuhan  Mencegah komplikasi  Mencegah perubahan mjd kronik 

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Prinsip: 

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Membuka sumbatan di KOM shg drainase dan ventilasi sinus2 pulih secara alami

Antibiotik dan dekongestan U/ menghilangkan infeksi  Yang dipilih → golongan penisilin  Alternatif: amoksisilin-klavulanat/jenis sefalosporin generasi ke-2  Diberikan selama 10-14 hari 

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Analgetik Mukolitik Steroid oral/topikal Pencucian rongga hidung dgn NaCl Pemanasan (diatermi) Antihistamin Tindakan Operasi → Bedah sinus endoskopi fungsional (BSEF/FESS)

KOMPLIKASI 

Kelainan orbita  Disebabkan

o/ sinus paranasal yg berdekatan dgn mata (orbita) → paling sering: sinusitis etmoid-frontal-maksila  Kelainan yg timbul:  Edema palpebra  Selulitis

orbita  Abses subperiostal  Abses orbita  Trombosis sinus kavernosum

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Kelainan intakranial  Kelainan

yg timbul:

 Meningitis  Abses

ekstradural/subdural  Abses otak  Trombosis sinus kavernosus

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Osteomielitis dan Abses Subperiostal  Paling

sering timbul akibat sinusitis frontal dan biasanya ditemukan pd anak2  Pd osteomielitis sinus maksila dpt timbul fistula oroantral/fistula pd pipi 

Kelainan paru → spt bronkitis kronik dan bronkiektasis

REFERENSI 

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Supardi EA, Iskandar N, Bashiruddin J, Restuti RD. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala & Leher. 7th ed. Jakarta: FKUI; 2015 Gray's Anatomy The Anatomical Basis of Clinical Practice, 40th Ed P. L. Dhingra, Shruti Dhingra-Diseases of Ear, Nose and Throat_ & Head and Neck Surgery-Elsevier India (2014)

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