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Nama : Dr. Cita Herawati Murjantyo, Sp THT-KL Tempat/tgl lahir : Yogyakarta, 15 Maret Pekerjaan/jabatan :
Staf Medik Fungsional RS Kanker Dharmais Bagian THT RSI Bintaro

Riwayat Pendidikan Formal

Spesialis THT, FKUI/RSCM-1998 Sedang pendidikan S3, Universitas Gajahmada Yogyakarta

Riwayat Pendidikan Tambahan

Endoscopic & Skull Base Surgery, Masterclass, Milano 2003 OSAS Obstructive Sleep Apnea Syndrome/SNORING, Singapore General Hospital, 2006 Head & Neck Course, Singapore General Hospital,2007 European Allergic Course, Greece, 2008

Cita Herawati RS Premier Bintaro

PERANAN AUGMENTIN PADA TERAPI RHINOSINUSITIS

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Anatomy of the sinus

Osteomeatal Complex

United Airway Disease

Integrated Airway System

Same histologic &

physiologic organ
Same pathology

mechanism
Same analogy &

hypothesis careful analysis & interpretation

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Rhinosinusitis Definition
AAO definitionDefined as an inflammation of the nose and sinuses

Rhinosinusitis
Include nasal airway

inflammation (Rhinitis)

Rhinosinusitis Symptoms
A rhinosinusitis task force in 1997 "major" criteria

facial pain nasal obstruction Hyposmia purulence on examination fever Headache Fatigue dental pain cough

"minor" criteria

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--

Viral Infection Self Limiting Disease

Unless There Is Secondary Bacterial Infection

Viral infections
Most common predisposing factors for

sinusitis in children Day care important risk

Reduce viral exposure among children

Prevention
Hand washing

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Distinguishing ABRS from ARS caused by viral upper respiratory infection

Term
Acute rhinosinusitis

Definition
Up to 4 weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain-pressure-fullness, or both: Purulent nasal discharge is cloudy or colored, in contrast to the clear secretions that typically accompany viral upper respiratory infection, and may be reported by the patient or observed on physical examination Nasal obstruction may be reported by the patient as nasal obstruction, congestion, blockage, or stuffiness, or may be diagnosed by physical examination Facial pain-pressure-fullness may involve the anterior face, periorbital region, or manifest with headache that is localized or diffuse Acute rhinosinusitis that is caused by, or is presumed to be caused by, viral infection. A clinician should diagnose VRS when: a. symptoms or signs of acute rhinosinusitis are present less than 10 days and the symptoms are not worsening Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterial infection. A clinician should diagnose ABRS when: a. symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or b. symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening)
(Adapted from ref 1)

Viral rhinosinusitis (VRS)

Acute bacterial rhinosinusitis (ABRS)

1.

Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline : Adult sinusitis. Otolaryngology Head & Neck Surgery; 2007; 137:S1-S31.

Classification by

Duration of

Symptoms
symptoms

ACUTE lasting up to 4 weeks, with total resolution of SUBACUTE persisting more than 4 weeks, but less than 12
weeks, with total resolution of symptoms

CHRONIC 12 weeks or more of signs / symptoms

RECURRENT ACUTE 4 or more episodes per year, with

resolution of symptoms between attacks

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2007

Acute Bacterial Rhinosinusitis

Gejala meningkat > 5 hari

Symptoms

Gejala menetap > 10 hari

Common Cold Acute Viral Rhinosinusitis 0 5 Hari

Fokkens W, Lund V, Mullol J, et al. Rhinology 2007 (Suppl 20): 1-136. 1web: www.rhinologyjounal.com / www.ep3os.org

10

15

12 Minggu

Rhinosinusitis Spectrum Based on Disease Duration

4 weeks 12 weeks

Acute Rhinosinusitis

Subacute Rhinosinusitis

Chronic Rhinosinusitis

Acute Recurrent Rhinosinusitis 3x in 6 months or 4x in 12 months Free of symptoms between episodes

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2007

Acute Rhinosinusitis Treatment

Symptomatic Treatment
Symptoms Intensity
Common Cold Acute Viral Rhinosinusisitis

+ Corticosteroid intranasal oral antibiotic

Acute Rhinosinusitis

Hari

10

15

Pathogenesis of ABRS changes from acute to chronic

In acute maxillary sinusitis S pneumoniae, H

influenzae, and M catarrhalis predominate

In chronic maxillary sinusitis anaerobic bacteria

are the main isolates

Peptostreptococcus, Fusobacterium, and pigmented Prevotella and Porphyromonas

-Lactamaseproducing bacteria were isolated

in 46% of the patients

2. Brook I. Bacteriology of Acute and Chronic Frontal Sinusitis. Arch Otolaryngol Head Neck Surg. 2002;128:583-58.

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Chronic rhinosinusitis (CRS)

Symptom-based diagnosis may be unreliable
Patient with sinus all the time,

chronic headache and facial pressure, plus stopped up nose; has had innumerable courses of antibiotics and 3 sinus operations by 2 different physicians

Computed tomography is the gold standard

Predisposing Factors In Chronic rhinosinusitis (CRS)

Host Factors
Systemic Allergic rhinitis Immunodeficiency
IgG subclasses IgA

Enviromental factors
Microorganisms

Genetic/congenital cystic fibrosis, ciliary dyskinesia

Local
Anatomic obstruction Gastroesophageal reflux

viral illness (children in daycare) Pollutants cigarette smoke Medications Rhinitis medicamentosa

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Possible Strategies for Treating CRS

Treat Etiology
Allergen Avoidance Antibiotics Surgery

Infectious Anatomic Allergy

Attenuate Inflammation
Steroids Immunotherapy Antileukotrienes Macrolides Who knows what else?

IL-5, IL-4 IL-8, IF- GM-CSF

CRS

Antibiotics in CRS
Should be based on culture results Endoscopic directed culture of purulent

secretions from the nasal vestibule or middle meatus correlate well with maxillary tap results S. aureus, Anaerobes & Gram negative Pseudomona Aeruginosa

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Antibiotics
First-line
amoxicillin-clavulanate amoxicillin cephalosporin second-or third-generation

Second-line
For adults The respiratory quinolones
ciprofloxin, levofloxacin, gatifloxacin, and moxifloxacin

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Augmentin in ABRS

TM

- Reliable efficacy

The Sinus and Allergy Health Partnership (SAHP) guidelines 7

Recommend any of the following as initial therapy in adults with mild disease who have not received antibiotics in the previous 4 to 6 weeks: amoxicillin-clavulanate, amoxicillin, cefpodoxime proxetil, cefuroxime axetil or cefdinir

Several guidelines include amoxicillin- clavulanate as a firstline/second-line treatment option (France, Germany, USA, Spain, UK, Belgium, Netherlands, Finland, Canada) 8

7. 8.

Poole MD, Portugal LG. Treatment of rhinosinusitis in the outpatient setting. Am J Med 2005;118 (7A):45S50S. Klossek JM, Federspil P. Update on treatment guidelines for acute bacterial sinusitis. Int J Clin Pract 2005; 59 (2): 230238

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Conclusion
CRS is multifactorial

Treatment is based on patients

predisposing factors
Therapeutic options
Prevent & treat etiology Reduce inflammatory response

Surgery
Exhaustion of medical option Certainty of diagnosis

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Thank you
9 April 2011

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