case sinusitis kronik

7/26/2019 Case SInusitis Kronik

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CASE PRESENTATION

Chronic Sinusitis

Supervisor :

dr. H. Oscar Djauhari, Sp. THT-KL

Presented by:Annisa Tri Handaani !"##$%""#"

Clinical Rotation

Ear Nose Throat Head and Neck Surgery Departent

!edical "aculty o# !uhaadiyah $akarta

Syasudin% S&H& Regional 'eneral Hospital% Sukabui

( !ay )*+, - +) $une )*+,

Id&ntit

Na'& ( )s. A

A*& ( !$ &ars o+dOccupation ( &'p+o&&


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&i*ht ( ! *

Addr&ss ( KP. Cipanas RT""/0""1, Cisarua

Chi&2 co'p+aint ( Stin stic &++o3ish dischar*& 2ro' th& nos&

Additiona+ co'p+aint ( 4u++n&ss and di22icu+t in 5r&athin* 2ro' th& ri*ht nos&

Histor o2 pr&s&nt i++n&ss

Th& pati&nt ca'& to th& hospita+ 3ith co'p+aints o2 stic &++o3ish dischar*& 2ro'

h&r ri*ht nos&. Th& dischar*& is not 'assi6&, 5ut it s'&++s 5ad. Sh& 2&+t this sinc& %

'onths a*o, sh& a+so 2&&+s th&r&7s so'& dischar*& 2+o3in* do3n on h&r 5ac throat.

Th& histor o2 2&6&r 3as positi6& # 'onth a*o 2o++o3&d 3ith du++ pain on h&r 2ac& and

ri*ht h&ad and radiat&s to th& t&&th, 3hich is *&ttin* 5&tt&r a2t&r sh& at& panado+ 2ort&.

Th&r& 3as a+so pro2us& nasa+ dischar*& at that ti'&. Curr&nt+ th& pati&nt a+so

co'p+aint o2 2u++n&ss and di22icu+t in 5r&athin* 2ro' h&r ri*ht nos&, sh& 2&&+s +i&

th&r& is so'&thin* o5structin* h&r ri*ht nos&, 'ain* h&r 6oic& s+i*ht+ chan*&d.Sh&

has 5&&n 2&&+in* this 2or a +on* ti'& 8a5out 'onths a*o9,.

Th& pati&nt d&ni&d th& pr&s&nc& o2 a++&r*, sn&&:in*, itchin* o2 th& nos&, d&cr&as& in

s'&++in* a5i+it 8hpos'ia9, r&c&nt co''on co+d or cou*h, trau'a on th& nos&, and

in2&ction o2 th& upp&r r&spirator tract. Sh& a+so d&n th& pr&s&nc& o2 pr&6ious 5+ood

dischar*& or pain 2ro' h&r nos&, histor o2 curr&nt+ tooth r&'o6a+, tootach&, and

ins&rtin* so'&thin* into h&r nos&. Th& pr&s&nc& o2 h&arin* ds2unction, 2u++n&ss in th&

&ar or an dischar*& 2ro' th& &ar is d&ni&d.

Curr&nt+ sh& is not tain* an dru*s '&dication, and th&r& is no 2a'i+ histor o2

tu'ors, h&arin* pro5+&'s, hp&rt&nsi6& dis&as&, dia5&t&s '&++itus.

Histor o2 past i++n&ss

Th& pati&nt d&ni&d th& histor o2 a++&r*, op&ration or an tooth r&'o6a+ proc&dur&,

hi*h 5+ood pr&ssur&, dia5&t&s '&++itus, a++&r* and in2&ction o2 th& nos&, &ar and throat

5&2or&.

Histor o2 2a'i+ i++n&ss

Histor o2 tu'or 8-9, a++&r* 8-9

Histor o2 hp&rt&nsion 8-9, dia5&t&s 8-9


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'eneral Physical E.aination

;&n&ra+ app&aranc& ( Th& pati&nt is ca+' Consciousn&ss ( Co'pos '&ntis

, +i6&r-

+un* 5ord&r at ri*ht 'idc+a6icu+ar ICS @

P&rcussion ( Sonor on 5oth h&'ithora>

Auscu+tation ( @&sicu+ar 5r&athin* B0B, 3h&&:in* -0-, rhonci -0-

A5do'&n (

Insp&ction ( App&ar 2+at, sicatrics8-9, disco+oration8-9, &n+ar*&d 6&ins8-9,

Pa+pation ( So2t on pa+pation, t&nd&rn&ss8-9, &n+ar*&d +i6&r8-9, &n+ar*&d sp+&&n8-9

P&rcussion ( T'pan on a++ a5do'ina+ r&*ion

Auscu+tation ( 5o3&+ sound8B9 nor'a+.

Sin (

ar' &>tr&'it, capi++ar r&2i++ ti'& % s&conds

Ear% Nose% Throat and neck Physical E.ainationARICLE

Ri*ht Auric+& (

E>t&rna+ &ar ( hp&r&'ic8-9, d&2or'it8-9, +ac&ration 8-9, 'ass 8-9, pain 8-9

E>t&rna+ acoustic cana+ ( hp&r&'ic8-9, &d&'a8-9, +ac&ration8-9, s&cr&tion8-9, c&ru'&n

8-9, 'ass8-9.

T'phanic '&'5ran& ( intact, +i*ht r&2+&>8B9 nor'a+

L&2t Auric+& (

E>t&rna+ &ar ( hp&r&'ic8-9, d&2or'it8-9, +ac&ration8-9, 'ass8-9, pain8-9

E>t&rna+ acoustic cana+ (hp&r&'ic8-9, &d&'a8-9, 'ass8-9, +ac&ration8-9, s&cr&tion8-9,c&ru'&n8-9, 'ass8-9.


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T'panic '&'5ran& ( intact, +i*ht r&2+&ct8B9 nor'a+

Ri*ht nos& ca6it (

E>t&rna+ nos& ( d&2or'ation8-9, &d&'a8-9, hp&r&'ic8-9, 'ass8-9,

+ac&ration8-9. )ucous '&'5ran& ( hp&r&'ic8-9, &d&'a8-9, s&cr&tion8-9, crust8-9, ass/01

#illing the nasal cavity% 2hite grapes coloured% slightly obile.

Concha& ( hp&rtrophic8-9, hp&r&'ic8-9, eatus secrete/01sticky non pro#use

yello2ish discharge above the in#erior concha.

S&ptu' ( no d&6iation

Air passa*& ( slightly obstructed

L&2t nos& ca6it (

E>t&rna+ nos& ( d&2or'ation8-9, &d&'a8-9, hp&r&'ic8-9, 'ass8-9,

+ac&ration8-9

)ucous '&'5ran& ( hp&r&'ic8-9, &d&'a8-9, s&cr&tion8-9, crust8-9, 'ass8-9.

Concha& ( hp&rtrophic8-9, hp&r&'ic8-9, '&atus s&cr&t&8-9

S&ptu' ( no d&6iation

Air passa*& ( nor'a+

Throat ( 6u+a is +ocat&d in th& 'idd+&, 'oist 'ucous '&'5ran&, 'ass8-9,

hp&r&'ic8-9, +&sion8-9.

Pharn> ( Nor'a+ pharn*&a+ arch,hp&r&'ic8-9, &d&'a8-9, *ranu+ation8-9

Nasopharyngeal laryngoscopy( Post nasal drip /01, 'ass 8-9, '&atus tu5a &ustachius 8B0B9,

corpus a+i&nu'8-9

Tonsi+s ( T# 0 T#, hp&r&'ic 8-9, &n+ar*&d crpts8-9, d&tritus8-9.

N&c ( L'phad&nopath c&r6ica+ +'ph nod& 8-9.

3orking diagnosis

Chronic rhinosinusitis 'a>i++aris uni+at&ra+ &t causa susp&ct o2 po+p on th& ri*ht nos&

Di##erential diagnosis

/-1

Suggestion

- Transi++u'ination t&st

- Radio+o*ic &>a'ination ( p+ain 2i+' >-ra o2 at&rs position, Su++ AP position

orcorona+ s&ctionCT-scan

- Naso&ndoscop

Therapy

- Su**&stion o2 4ESS 84unctiona+ Endoscopic Sinus Sur*&r9- Nasa+ 3ash 3ith C&2ta:idi'& and sa+in& so+ution


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Chronic Sinusitis

De#inition

Chronic sinusitis is th& in2&ction o2 th& sinus 'ucosa, 3hich is usua++ du& to th& o5struction

o2 th& ost&o'&ata+ unit. Th& distinction o2 acut& and chronic in2&ction o2 th& sinusitis is that

acut& in2&ction usua++ +ast up to ! 3&&s, '&an3hi+& th& chronic in2&ction 'a p&rsist up to

#! 3&&s or 'or&.

4natoy

Paranasa+ sinus&s ar& 'ucosa-+in&d structur&s continuous 3ith th& nasa+ ca6it. Th& 2unctions

ar&(

- Actin* as r&sonatin* cha'5&rs 2or th& 6oic&

- Pro6id& prot&ction to th& 5rain 2ro' trau'a

- )oisturi:& and hu'idi2 a'5i&nt air

- Li*ht&nin* th& 3&i*ht o2 th& 2acia+ s&+&ton

Th& s&cr&t&s 2or'&d in th& sinus&s ar& drain&d to th&ir p&rsp&cti6& '&atus. Th&r& ar& thr&&

'&atus, th& sup&rior, '&dia, and in2&rior '&atus. Th& sup&rior '&atus drains s&cr&t&s 2ro'

th& post&rior &th'oida+ c&++s th& '&dia '&atus throu*h th& s&'i+unaris hiatus drains s&cr&t&s

2ro' th& 2ronta+ sinus&s, ant&rior &th'oida+, and 'a>i++ar sinus&s and th& in2&rior '&atus

drains s&cr&t&s 2ro' th& naso+acri'a+ duct.

Th& ost&o'&ata+ co'p+&> is a s'a++ constrict&d r&*ion 3hich is pron& to o5struction,

&sp&cia++ in th& pr&s&nc& o2 con*&nita+ ano'a+8Concha 5u++osa, s&pta+ d&6iation, s&pta+

spurs9, in2&ction, tu'ors8po+p9, trau'a8anato'ic d&6iations, s&pta+ d&6iations9, and

oth&rs8a++&r*ic rhinitis, 2or&i*n 5odi&s9

Fig. 1.1 Lateral of nasal


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Risk "actors

Th& anato'ica+ a5nor'a+iti&s such as s&pta+ d&6iation, 5u++a &th'oida+is, concha 5u++osa,

pro'in&nt uncinat& proc&ss, narro3 2ronta+ r&c&ss, and nasa+ po+ps 'a 5+oc th& sinus&s

ostia.Th& conditions 3hich i'pairs th& 'ucoci+iar transport such as a++&r*ic rhinitis, nasa+

po+posis, cstic 2i5rosis, pri'ar ci+iar dsin&sia, and Karta*&n&r7s or oun*7s sndro'&.

4ai+ur& o2 th& 'ucoci+iar c+&aranc& 2ro' th& sinus&s throu*h th& ostia 'a +&ad to th& stasis

and th& 2or'ation o2 pus in th& sinus.

Ci*arr&tt& s'oin* 'a a+so a22&ct th& 'ucoci+iar c+&aranc& ds2unction 3hich in turns

r&su+t in th& r&t&ntion o2 th& s&cr&t&s in th& sinus&s.

Pathophysiology

)ost o2 th& chronic sinusitis in2&ction is usua++ 5act&ria+, 3hich d&6&+op s&condar to th&

pri'ar 6ira+ sinusitis. hi+& th& acut& sinusitis in2&ction is 'ost+ du& to th& Str&ptococca+

and oth&r a&ro5ic 5act&ria, chronic sinusitis 'ain+ du& to th& accu'u+ation o2 ana&ro5ic

5act&ria.

4erobic 5acteria 4naerobic bacteriaStreptoccocus Pneumonia

Haemophilus Influenzae

Streptococcus Group A

Moraxella Catarrhalis

Pseudomonas sp.

le!siella sp.

Peptostreptococcus

"acteroides spp.

#uso!acteria

Th& ori*in o2 th& 'a>i++ar sinusitis 'a 5& &ith&r d&nto*&n or rhino*&n. Th& +ocation o2 th&

a+6&o+ar 5on& o2 th& tooth +i&s c+os& to th& 5as& o2 th& 'a>i++ar sinus, 3hich th&r&2or& a++o3s

a dir&ct trans'ission o2 'icroor*anis' 2ro' th& 'outh to th& sinus. D&nto*&n ori*in usua++

r&su+ts 2ro' th& &>traction o2 th& tooth 3hich accid&nta++ t&ars th& thin 5on& 5&t3&&n th&

sinus - a+6&o+ar 5on& and th&r&2or& 'ain* an op&n conn&ction 5&t3&&n th& ora+ ca6it and

th& 'a>i++ar sinus, this is ca++&d th& oro-antra+ 2istu+a.

Rhino*&n ori*in is 'ost+ du& to th& i'pair&d 6&nti+ation '&chanis' o2 th& ost&o'&ata+ unit

s&condar to st&nosis or o5struction 8 s3&++in* o2 th& nasa+ 'ucosa, '&chanica+ o5struction9.

Th& 2ai+ur& o2 th& 'ucoci+iar c+&aranc& 3i++ r&su+t in s&cr&t& accu'u+ation 3hich a 5+octh& sinus op&nin*s.Th& 5+oc&d draina*& o2 th& sinus sst&' 8adjac&nt 'a>i++ar sinus0

60%

Mostly dentogen

etoiology


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ant&rior &th'oida+ c&++s, 2ronta+ sinus&s9 caus& th& s3&++in* o2 th& narro3 ost&o'&ata+ unit.

This &sta5+ish a 6icious cc+& and 'a +&ad to r&curr&nt acut& in2+a''ation and &6&ntua++

th& p&rsist&nt chronic sinusitis. Chronic sinusitis 'ost+ a22&ct th& 'a>i++ar sinus and

&th'oida+ c&++s, and +&ss a22&ct th& 2ronta+ and sph&noid sinus&s.

F A. Chonca 5u++osa 8pn&u'ati:&d 'idd+& tur5inat&9


8/9

Hadleys clinical scoringo2 nasa+ po+p (

;rad& I ( S'a++ po+p, +ocat&d 3ithin th& 'idd+& '&atus, and not &>c&&din* th&

in2&rior part o2 th& 'idd+& concha.

;rad& II ( Po+p 3ithin '&atus and &>c&&din* th& i2&rior part o2 th& 'idd+&

concha.

;rad& III ( Po+p can 5& s&&n in th& nasa+ ca6it, &>c&&din* th& 'idd+& concha,

ho3&6&r do not &>c&&d th& in2&rior part o2 th& 'idd+& concha.

;rad& I@ ( Po+p co6&rs th& &ntir& nasa+ ca6it.

Diagnosis

Dia*nosis o2 chronic sinusitis can 5& 'ad& 3ith th& us& o2 rhinoscop and &ndoscop o2 th&

nasa+ ca6it, o5s&r6in* th& +at&ra+ 3a++ o2 th& nos& 8o5struct&d '&atus, s&cr&t& in th& '&atus9and th& post nasa+ drip.

P+ain 2i+' radio*raph such as th& 3at&rs position 'a sho3 th& opaci2ication o2 th& sinus&s

in6o+6&d, and th& upri*ht position to sho3 th& air-2+uid +&6&+ in th& sinus&s in6o+6&d.

Th& 5&st instru'&nt to dia*nos& th& chronic sinusitis is th& us& o2 CT scan, 3h&r& 3& can

o5s&r6& (

- Th& in2undi5u+ar patt&rn 8o5struction in th& 'a>i++ar in2undi5u+u', r&su+tin* in

iso+at&d 'a>i++ar sinusitis9

- Ost&o'&ata+ unit patt&rn 8'idd+& '&atus o5struction +&adin* to ipsi+at&ra+ sinusitisG

a22&ctin* th& 2ronta+, 'a>i++ar sinus&s, and th& ant&rior o2 th& &th'oid c&++s9

- Th& sph&no&th'oid r&c&ss 8o5struction r&su+ts in post&rior &th'oid and sph&noid

sinusitis9

- Sinonasa+ po+posis patt&rn 8opaci2ication o2 tissu&s9

- nc+assi2i&d 8 'ucoc&+&s, 'ucosa+ thic&nin* 3ithout o5struction, r&t&ntion cst9

Coplication

Inco'p+&t& tr&at'&nt o2 th& sinusitis 'a r&su+t in th& co'p+ication du& to th& &>t&nsion o2

th& in2&ction to th& adjac&nt structur&s(

A. Or5ita+ C&++u+itis

)ost+ occurs in chi+dr&n 3h&r& th& &th'oid sinus7s in2&ct&d. In2&ction spr&ads 2ro'

th& +a'ina paprac&a into th& or5it, passin* throu*h th& 5on d&hic&nc&s or throu*h

th& thro5os&d co''unicatin* 6&ss&+s. Initia+ 'ani2&station 'a 5& c&++u+itis, th&n to


9/9

th& pr& s&pta+ in2&ction 3hich 'a &nd up 3ith post s&pta+ in2&ction. Th& 2or'ation o2

a5sc&ss 'a i'pair 6ision.

i++ar sinus 'ucoc&+& 'a

r&su+t in s3&++in* o2 th& ch&&, and sph&noid sinus 'ucoc&+& 'a r&su+t in ocu+o'otor

pa+s.

Treatent

Th& op&rati6& tr&at'&nt o2 chronic sinusitis 8a+so 3ith th& nasa+ po+p9 'i*ht 5& th& 4ESS

84unctiona+ Endoscopic Sinus Sur*&r9 3hich is +&ss in6asi6& and 'a 5& satis2actor.

Th& non-op&rati6& tr&at'&nt o2 chronic sinusitis 'ust 5& ad&uat& to tr&at 5oth a&ro5ic and

ana&ro5ic 5act&ria (

- A'o>ici++in0 c+a6u+anat&

- A+t&rnati6& ( )&tronida:o+& B L&2o2+o>acin

- Irri*ation o2 th& nasa+ ca6it 3ith c&2ta:idi'&

Early or"ital cell!litis A"scess

formation

Maxillary #p$enoid Frontal

case sinusitis kronik

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