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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
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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
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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