Rinologi

Dr. M Nurman Hikmallah, SpTHT SMF THT RSUD TRIPAT GERUNG Lombok Barat

Sinus Paranasal

4 SINUS PARA NASAL 1. Sinus Frontal 2. Sinus Sphenoid 3. Sinus Ethmoid 4. Sinus Maksila

Fungsi sinus

Air conditioning Keseimbangan kepala Menjaga suhu Resonansi

Fungsi normal sinus tergantung pd ventilasi & drainase yg baik

Anatomi Sinus

Sinus Maksila

Terbesar, piramid Basis : dinding lateral rgg hidung Apek : proc Zygomatikus

Sinus Maksila
Batas2 : Anterior : permk fasial sinus maksila Posterior : fosa infra temporal & Pterigomaksila Medial : dinding lateral hidung Superior : dasar orbita Inferior : proc alveolaris & palatum

Sinus maksila
Anatomi klinik

Dasar sinus dekat dengan gigi PM 1 & 2 Batas superior dekat mata Osteum sinus lebih tinggi dari dasarnya Diameter ostium 1-3mm

Sinus maksila

Terbentuk sejak lahir Pada anak : dasar sama / > tinggi dari dasar rongga hidung Ukuran Sinus Lahir : 7-8 x 4-6 mm Dewasa : Medio lateral : 3-5 cm

Antero posterior : 2-5 cm Volume: 15-30 mL

Sinus maksila

Vaskularisasi : a. maksila interna a. sphenopalatina a. palatina mayor a. alveolaris anterior - posterior

Sinus maksila
Histologi & fisiologi : Mukosa : . lanjutan cavum nasi ( > tipis ) . epitel kolumner pseudokomplek bersilia

Sinus frontal

Sempurna usia > 8 tahun Batas dengan orbita tipis

Muara di meatus medius

( bersama dg sinus maksila & sinus ethmoid )

Sinus Ethmoid

3-16 Sel-sel ( sarang lebah ) volume total 3 ml Letak : bula ethmoid, diantara konka media & ddng medial orbita Jumlah : 2 kelompok S. Ethmoid anterior muara meatus media S. Ethmoid posterior muara meatus superior

Sinus Ethmoid

Batas batasnya Lateral : Lamina papirasea ( mata) Superior : Lamina kribosa Posterior : Sinus sphenoid

Sinus Sphenoid

Letak : di dalam os sphenoid Batas batas : Superior : fosa cerebri media Inferior : atap nasofaring Lateral : sinus cavernosus & a. carotis interna Posterior : Pons / fosa cerebri posterior

Komplek ostiomeatal
Celah sempit yg merupakan unit drainase fungsional ta : bula ethmoid, prosesus uncinatus, infundibulum ethmoid, hiatus semilunaris, ostium sinus maksila, resesus frontalis

SINUSITIS

Inflamasi pada satu atau lebih mukosa sinus paranasal baik karena infeksi dan non infeksi dg gejala : * hidung buntu, * nyeri fasial dan ingus kental /purulen.

SINUSITIS
American Academy of Otolaryngology Head and Neck Surgery ( 1996 ) : Sinusitis Rinosinusitis

Alasan : Mukosa hidung & sinus secara embriologis berhub Pend sinusitis juga rinitis ( jarang yang tidak) Gjl pilek, hidung buntu, hiposmia ada pd keduanya CT pend C Cold inflamasi mukosa hdng & sinus Kasus sinusitis lanjutan dari sinusitis

konsep one air one disease

SINUSITIS

Morbiditas tinggi AS : 30 juta penderita ( 1989 ) 90 % ke pelayanan primer Indonesia : data epidemiologik : ( - ) dx dasar konfirmasi : x foto therapi tidak adekuat kronik

Pengetahuan Patogenesis
penting untuk :

Ketrampilan diagnosis sinusitis Pemberian terapi tepat dan adekuat Menurunkan : Morbiditas Angka absen Lama sakit Biaya pengobatan

PATOGENESIS

Dengan C.T. : - Struktur sinus - Kompleks ostiomeatal Sinusitis disertai kelainan kompleks ostiomeatal Sinus sehat : bakteri aerob dan anaerob dlm sinus

PATOGENESIS
- Kelainan/ obstruksi komplek ostiomeatal - Bakteri dalam rongga sinus

- Adanya faktor predisposisi

SIKLUS SINUSITIS

Faktor predisposisi
Berbagai kondisi yang mengarah pada obstruksi sinus : infeksi & alergi
Berbagai variasi anatomis : septum deviasi, konka bulosa, kKurvatura paradoksal konka media Gangguan klirens mukosilia : sindrom diskinesia ( Kartegener, silia imotil ), fibrosis kistik. Imunosupresi atau imun defisiensi

SIKLUS SINUSITIS
Sekret kental Sekret terbendung
Kongesti mukosa / obstruksi anatomik hentikan aliran udara dan drainase Perubahan met. gas mukosa Silia & epitel rusak Perbhn lingk. baik utk pertumb bakteri di rgg tertutup

Ostium tertutup Penebalan mukosa sumbatan lebih lanjut

Sekret yg tertimbun inflamasi jaringan
Infeksi bakteri dalam rongga sinus

Etiologi / penyebab sinusitis

Virus : Corona virus, Rhinovrus, Influenza A, RSV Bakteria aerob: Streptokokus pnemoni, H influenzae, Moraxella catarhalis, Streptokokus pyogenes, Staphylokokus aureus Bakteri anaerob

Diagnosis Sinusitis
Anamnesis
Sering dianggap pilek biasa yg tak kunjung hilang Ingus kental, sepanjang hari Suara kadang sengau / nasolalia klausa Sakit kepala, sesuai lokasi sinus yang sakit Batuk, terutama pada anak Foetor ex nasi

Pemeriksaan fisik

Nyeri ketok daerah pipi / dahi Rinoskopi anterior :

* mukosa hidung edem, hiperemi * sekret mukopurulen kental

* warna kuning-kehijauan di kavum nasi dan

meatus medius

Pemeriksaan faring :

Drainase post nasal

Konfirmasi diagnosis

X foto sinus para nasal Pungsi sinus CT Scan

Cairan dalam sinus

Diagnosis Klinik sinusitis :

Kriteria Saphiro & Rachelefsky 1992

Mayor
Rhinorhe purulen Drainase post nasal

Minor
demam nyeri kepala dan sinus foetor

Batuk

Sinusitis : 2 mayor
1 mayor + 2 / lebih minor

Task Forse AAOA dan ARS ( 1997)

Gejala mayor : Sakit pada muka ( pipi, dahi, hidung) Buntu hidung Ingus purulen Gangguan penciuman pem hidung : ingus purulen

SINUSITIS ?

Gejala minor : Batuk, demam ( yang akut ) Nyeri kepala Nyeri geraham Halitosis Tenggorok berlendir

Dua gejala mayor atau lebih, atau Satu gejala mayor disertai 2 gejala minor

PENGOBATAN
Sinusitis Akut
Antibiotika spektrum luas Dosis cukup, 10-21 hari Dekongestan hidung ( topikal/ sistemik ) Mukolitik

PENGOBATAN

Sinusitis Kronik
- Antibiotika sesuai hasil kultur - Dekongestan hidung - Mukolitik minimal 10-14 hari tak terkontrol ? * Irigasi sinus (maks 5x) tak sembuh ? * FESS * Operasi Cald-Well-Luc (CWL)

ALLERGIC RHINITIS :

The most prevalent of type I allergic dis. The symptoms and signs caused by mediators : vessels, glands and nerves. Classified as inflammatory disease.

ALLERGIC RHINITIS :

Sign & symptoms :

Itching nose Sneezing Rhinorrhea Nasal obstruction

Allergic salute

EPIDEMIOLOGY

Prevalence in ISAAC (Asher 1995) : 0.8 14.95 % in 6-7 years old 1.4 39.7 % in 13 14 years old Low pervalence : Indonesia, Georgia, Greece Semarang (2002) ISAAC phase 3, RA : 18,6% High pervalence : Australia, UK and Latin Americ In adults : no equivalent to ISAAC study National survey : 5.9 % France and 29 % UK

WHO Classification of Allergic rhinitis

1.

2.

INTERMITTENT Less than 4 days a week, or Less than 4 weeks PERSISTENT More than 4 days a week, and More than 4 weeks

SEVERITY OF THE DISEASE

MILD means no one of the following items are present

1.

Sleep disturbance Impairment of daily activities / sport Impairment of school / work Troublesome symptoms

2.

MODERATE SEVERE, when one or more of the symptoms are present

MECHANISMS OF Allergic RHINITIS

Mast cell IgE allergen Immediate rhinitis symptoms Histamine Leukotrienes Itch, sneezing Prostaglandin's Watery discharge Bradykinin,PAF Nasal congestion

B cell
IL4 Chronic ongoing rhinitis

Th2 cell
IL 3, 5, GMCSF

eosinophils

Nasal blockade Loss of smell Nasal hyperreactivity

MAST CELL DEGRANULATION allergen Y Y Newly formed mediators

PLA2 AA + PAF
C.O 5 L.O

PGD2

LTC4 LTD4 LTE4

LTB

Preformed mediators Histamine, Heparin, Tryptase, TNF , TGF , IL 3, 4, 5, 13

HISTAMINE EFFECTS
HISTAMINE DEGRADATION H1-R Nociceptive Nerves Vascular wall

( histamine methyl transfera

CNS
Itch. Systemic Reflexes Sneeze Allergic Salute Parasympathic Reflexes Glandular Exocytosis

Endothelium
(Vascular Permeability)

Vasodilatation
Serous/Mucous Secretion

Diagram of DIAGNOSTIC PROCEDURES (1)

patients with AR symptoms

skin prick test

( history of illness + physical exam.)

(+) AR with AR without complications / complication concomitant dis

(-) eosinophil on nasal cytology

(+)
NARES

(-)

allergic Rhinitis ?

non allergic rhinitis

Diagnostic Procedures (2)

1.

Anamnesis
Chief complain :
1. 2. 3.

Itching nose Sneezing : morning >> Serous nasal secretion

4.

Nasal obstruction at night

Diagnostic Procedures (3)

1. Anamnesis

The symptoms was environment related History of other allergic manifestation of patients and other allergic familial manifestations Duration of illness, severity of the disease and the respond of the previous treatment

Diagnostic Procedures
2. Physical examination
Should be performed with appropriate lighting and use of nasal speculum

normal

oedema

Diagnostic Procedures (5)

2. Physical examination

Including :
1.
2. 3.

Nasal passage ways

Nasal mucosa Turbinates

4.
5. 6. 7.

Secretion
Septum Polyps ? Sinusitis ?

Diagnostic Procedures (6)

3. Nasal cytology

Large number of eosinophils may aid to differentiate AR & NARES from other Rhinitis
No consensus to routinely performed for evaluation of rhinitis

Diagnostic Procedures (7)

4. Total serum Ig E

Neither very sensitive nor very specific 35 50 % AR Normal Ig E levels

Poor correlation with symptom and skin testing result

Diagnostic Procedures (8)

5. Nasal provocation testing

Based on a history of AR symptoms provoked by allergen exposure and confirmed by skin testing It may be required for confirmation of sensitivity to allergen in the work place

Diagnostic Procedures (9)

6. Special diagnostic techniques

Upper airway endoscopy / Rhinomanometry

Standard radiographs
CT

MRI

Diagnostic Procedures (10)

7. Testing for specific Ig E, important for :

Determining whether patient has allergic rhinitis

Identifying specific allergen for avoidance measurement and allergen immunotherapy

Diagnostic Procedures (11)

8. Skin testing to allergen : Simple Ease Rapid performance Low cost High sensitivity / spesificity ( Prick test )

Allergy skin prick testing

Skin prick test :

positive result
wheal > 3mm diameter

A R and other diseases

OME
U R T infection

Allergic Rhinitis Bronkhial asthma Sinusitis

Nasal polyp

Comorbidity AR and Sinusitis

US : sinusitis 30 Mill / year (1989 ) sinusitis : 25 30 % AR non sinusitis : 14 17 % AR Sinusitis ( dx CT ) Newman at all 1994 : AR : 78 % Asthma : 71 %

Differential diagnosis of RA
Non allergic rhinitis : Infectious : bacterial, viral, fungal Drug induced : aspirin & other medications Occupational rhinitis (allergy & non allergy) Hormonal : puberty, pregnancy, menstruation and hormonal disorders Other causes : foods, irritants, emotions, NARES Atrophic Rhinitis Idiopatic

Management of AR
Objectives :

relieving symptoms for improving QOL to avoid triggering factor to avoid / to treat complication

to change the natural history

Allergen elimination
EDUCATION

Explain what is allergic rhinitis / reaction Explain the meaning of pos. allergic skin test Confirm whether there is correlation between allergen contact & rhinitis attack Explain how to do allergen avoidance

Encourage to avoid the allergens

Globally important allergens

mites

mites sources

pets : dogs cockroaches

pollen

weed

 Pharmacological treatment
1.

ANTIHISTAMINE First line Consider new antihistamine since : Long acting more practical No sedating normal daily activity No / less cardiac effect Broad spectrum effects Except : Patient doesnt mind sedation effect It is not available Can not be afforded Classic antihistamine can be considered

2. NASAL DECONGESTANT Indicated in patient with prominent nasal obstruction complaint

As addition / combination with A H

Long term treatment Systemic nasal decongestant, be careful in hypertension cases and glaucoma. Topical : rebound effect

3. INTRANASAL CORTICOSTEROID

Long term treatment safer than systemic application Effective to control AR symptoms

Note : Patients should be well informed how to use Symptoms relieve is not directly achieved In some places it is unavailable

 Allergen Specific Immunotherapy ( ASIT )

ASIT : effective for treating allergic rhinitis

Recommended in patients with :

severe symptoms failed by pharmacological treatment positive correlation skin test & history agree & well informed about duration, schedule of injection & expected results

Intermittent AR : Adults & children

Is therapy needed ? If yes

Non-pharmacological therapy Allergen avoidance measure

Is pharmacotherapy needed ? If yes

Mild disease Oral/nasal AH or cromon Moderate disease Nasal corticosteroids Severe disease

Nasal CS & oral/ nasal AH

If inadequate control

Add further symptomatic treatment Or Short course oral CS Or Consider IT

Persistent AR : Adults Is therapy needed ? If yes

Non-pharmacological therapy Allergen avoidance measure Environment control

Is pharmacotherapy needed ? If yes

Mild disease Oral/ nasal antihistamine Moderate disease Nasal corticosteroids Severe disease

Nasal CS & Oral antihistamine

If inadequate control

If resistent

If resistent
Nasal blockage

Antihistamine and Oral / nasal decongestant Or Short course oral steroid

Rhinorrhea Nasal ipratropium bromide

If persistent
Consider Immunotherapy

If inadequate control
Further examination & consider immunotherapy Or Surgical turbinate reduction