Rhinologi(Sinusitis)& RA

8/13/2019 Rhinologi(Sinusitis)& RA

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Rinologi

Dr. M Nurman Hikmallah, SpTHT

SMF THT RSUD TRIPAT GERUNG

Lombok Barat


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Sinus Paranasal

4 SINUS PARA NASAL

1. Sinus Frontal

2. Sinus Sphenoid3. Sinus Ethmoid

4. Sinus Maksila


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Fungsi sinus

Air conditioning

Keseimbangan kepala

Menjaga suhu Resonansi

Fungsi normal sinus tergantung pd ventilasi& drainase yg baik


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AnatomiSinus


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Sinus Maksila Terbesar, piramid

Basis : dinding lateral rgg hidung

Apek : proc Zygomatikus


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Sinus Maksila

Batas2 :

Anterior : permk fasial sinus maksila

Posterior : fosa infra temporal &Pterigomaksila

Medial : dinding lateral hidung

Superior : dasar orbita Inferior : proc alveolaris & palatum


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Sinus maksila

Anatomi klinik

Dasar sinus dekat dengangigi PM 1 & 2

Batas superior dekat mata

Osteum sinus lebih tinggidari dasarnya

Diameter ostium 1-3mm


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Sinus maksila

Terbentuk sejak lahir Pada anak : dasar sama / > tinggi dari

dasar rongga hidung

Ukuran SinusLahir : 7-8 x 4-6 mm

Dewasa : Medio lateral : 3-5 cm

Antero posterior : 2-5 cmVolume : 15-30 mL


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Sinus maksila

Vaskularisasi :

a. maksila interna

a. sphenopalatina

a. palatina mayor

a. alveolaris anterior - posterior


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Sinus maksila

Histologi & fisiologi :

Mukosa : . lanjutan cavum nasi ( > tipis )

. epitel kolumner pseudo-

komplek bersilia


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Sinus frontal

Sempurna usia > 8 tahun

Batas dengan orbita tipis

Muara di meatus medius

( bersama dg sinus maksila & sinus

ethmoid)


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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


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Sinus Ethmoid

Batasbatasnya

Lateral : Lamina papirasea ( mata)

Superior : Lamina kribosa

Posterior : Sinus sphenoid


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Sinus Sphenoid

Letak : di dalam os sphenoid Batasbatas :

Superior : fosa cerebri media

Inferior : atap nasofaring Lateral : sinus cavernosus &

a. carotis interna

Posterior : Pons / fosa cerebri

posterior


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Komplek ostiomeatal

Celah sempit yg merupakan unit drainase

fungsional ta :

bula ethmoid,

prosesus uncinatus,

infundibulum ethmoid,

hiatus semilunaris,

ostium sinus maksila,resesus frontalis


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SINUSITIS

Inflamasi pada satu atau lebih mukosa

sinus paranasal baik karena infeksi dannon infeksi dg gejala :

* hidung buntu,

* nyeri fasial dan ingus kental /purulen.


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American Academy of OtolaryngologyHead and Neck

Surgery ( 1996 ) : Sinusitis Rinosinusitis

SINUSITIS

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


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Morbiditas tinggi

AS : 30 juta penderita ( 1989 )

90 % ke pelayanan primer

Indonesia :

data epidemiologik : ( - ) dx dasar konfirmasi : x foto

therapi tidak adekuat kronik

SINUSITIS


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Pengetahuan Patogenesis

Ketrampilan diagnosis sinusitis

Pemberian terapi tepat dan adekuat

Menurunkan : Morbiditas

Angka absen

Lama sakit

Biaya pengobatan

penting untuk :


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PATOGENESIS

Dengan C.T. :

- Struktur sinus

- Kompleks ostiomeatal

Sinusitis disertai kelainan

kompleks ostiomeatal

Sinus sehat : bakteri aerob dan

anaerob dlm sinus


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PATOGENESIS

- Kelainan/ obstruksi komplek

ostiomeatal

- Bakteri dalam rongga sinus

- Adanya faktor predisposisi

SIKLUS SINUSITIS


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Faktor predisposisi

Berbagai kondisi yang mengarah pada obstruksi

sinus : infeksi & alergi

Berbagai variasi anatomis : septum deviasi,

konka bulosa, kKurvatura paradoksal konkamedia

Gangguan klirens mukosilia : sindrom diskinesia

( Kartegener, silia imotil ), fibrosis kistik.

Imunosupresi atau imun defisiensi


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SIKLUS SINUSITIS

Sekret kental

Perubahanmet. gas mukosa

Silia & epitel rusak

Perbhn lingk. baik utk pertumb

bakteri di rgg tertutup

Sekret yg tertimbun

inflamasi jaringan

Infeksi bakteri dalam

rongga sinus

Penebalan mukosa

sumbatan lebih lanjut

Ostium tertutup

Kongesti mukosa / obstruksi

anatomik hentikan aliran udara

dan drainase

Sekret terbendung


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Etiologi / penyebab sinusitis

Virus :

Corona virus, Rhinovrus, Influenza A, RSV

Bakteria aerob:

Streptokokus pnemoni,H influenzae,

Moraxella catarhalis,

Streptokokus pyogenes,

Staphylokokus aureus

Bakteri anaerob


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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


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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


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Konfirmasi diagnosis

Xfoto sinus para nasal

Pungsi sinus

CTScan

Cairan dalam sinus

Di i Kli ik i iti


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Kriteria Saphiro & Rachelefsky 1992

Rhinorhe purulen

Drainase post nasalBatuk

Mayor

demam

nyeri kepala dan sinus

foetor

Minor

Sinusitis : 2 mayor

1mayor + 2 / lebih minor

Diagnosis Klinik sinusitis :


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T


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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)


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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 :


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Sign & symptoms : Itching nose

Sneezing

Rhinorrhea Nasal obstruction

Allergic salute

ALLERGIC RHINITIS :


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EPIDEMIOLOGY

Prevalence in ISAAC (Asher 1995) :0.814.95 % in 6-7 years old

1.439.7 % in 1314 years old

Low pervalence : Indonesia, Georgia, Greece Semarang (2002) ISAAC phase 3, RA : 18,6%

High pervalence : Australia, UK and Latin Ameri

In adults : no equivalent to ISAAC study National survey : 5.9 % France and 29 % UK

WHO Cl ifi i f


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WHO Classification of

Allergic rhinitis

1. INTERMITTENT

Less than 4 days a week, or

Less than 4 weeks

2. PERSISTENT

More than 4 days a week, and

More than 4 weeks

SEVERITY OF THE DISEASE


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SEVERITY OF THE DISEASE

1. MILDmeans no one of the following items

are present

Sleep disturbance

Impairment of daily activities / sport

Impairment of school / work

Troublesome symptoms

2. MODERATESEVERE, when one or more

of the symptoms are present


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MECHANISMS OF Allergic RHINITIS

Mast cell

Histamine

LeukotrienesProstaglandin's

Bradykinin,PAF

Itch, sneezingWatery discharge

Nasal congestion

allergen

Th2 cell

B cell

eosinophils Nasal blockadeLoss of smell

Nasal hyperreactivity

IL4

IgE

IL 3, 5, GMCSF

Immediate rhinitis symptoms

Chronic ongoing rhinitis

MAST CELL DEGRANULATION


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MAST CELL DEGRANULATION

Histamine, Heparin, Tryptase,

TNF , TGF , IL 3, 4, 5, 13

Newly formed mediators

PLA2 AA + PAF

C.O 5 L.O

PGD2 LTC4 LTB

LTD4

LTE4

Yallergen

Preformed mediators

Y

HISTAMINE EFFECTS


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HISTAMINE

H1-R

DEGRADATION

( histamine methyl transfer

CNS Endothelium(Vascular Permeability)

Nociceptive Nerves

Itch.

Systemic ReflexesSneeze

Allergic Salute

Serous/Mucous Secretion

Parasympathic Reflexes

Glandular Exocytosis

HISTAMINE EFFECTS

Vascular wall

Vasodilatation

Diagram of DIAGNOSTIC PROCEDURES


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Diagram of DIAGNOSTIC PROCEDURES(1)

patients with AR symptoms( history of illness + physical exam.)

skin prick test

(+)

AR withcomplications /concomitant dis

AR withoutcomplication

eosinophil onnasal cytology

(+)

allergicRhinitis ?

(-)

non allergicrhinitis

NARES

(-)

Di ti P d (2)


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Diagnostic Procedures (2)

1. Anamnesis

Chief complain :

1. Itching nose

2. Sneezing : morning >>

3.

Serous nasal secretion4. Nasal obstruction at night


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Diagnostic Procedures

2. Physical examination

Should be performed with appropriate

lighting and use of nasal speculum

normaloedema


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2. Physical examination

Including :

1. Nasal passage ways

2. Nasal mucosa

3. Turbinates

4. Secretion

5. Septum

6. Polyps ?

7. Sinusitis ?


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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


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5. Nasal provocation testing

Based on a history of AR symptoms

provoked by allergen exposure andconfirmed by skin testing

It may be required for confirmation of

sensitivity to allergen in the work place



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6. Special diagnostic techniques

Upper airway endoscopy /

Rhinomanometry

Standard radiographs

CT

MRI


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8.Skin testing to allergen:

Simple

Ease

Rapid performance

Low cost

High sensitivity / spesificity

( Prick test )

Allergy skin prick testing


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Allergy skin prick testing

Skin prick test :

positive result

wheal > 3mm diameter


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anagement o


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g

Objectives :

relieving symptoms for improving QOL

to avoid triggering factor

to avoid / to treat complication

to change the natural history


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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


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Globally important allergens

mites

pollen

mites sources

weed cockroaches

pets : dogs

Pharmacological treatment


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g

1. ANTIHISTAMINE

First line Consider new antihistamine since :

Long actingmore practical

No sedatingnormal 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


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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


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3. INTRANASAL CORTICOSTEROID

Long term treatment safer than systemicapplication

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


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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


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Is therapy needed ? If yes

Non-pharmacological therapy

Allergen avoidance measure

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/nasal AH or

cromon

Nasal

corticosteroids

Nasal CS & oral/

nasal AH

Add further symptomatic

treatment

Or

Short course oral CS

Or

Consider IT

If inadequate

control

Persistent AR : Adults Is therapy needed ? If yes


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Non-pharmacological therapy

Allergen avoidance measure

Environment control

Is pharmacotherapy needed ? If yes

Mild disease Moderate disease Severe disease

Oral/ nasal

antihistamine

Nasal

corticosteroids

Nasal CS &

Oral antihistamine

If inadequate

control If resistent

I f resistent


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Nasal blockage

RhinorrheaAntihistamine and

Oral / nasal

decongestant

Or

Short course oral

steroid

Nasal ipratropium

bromide

I f persistent

Consider

Immunotherapy

I f inadequate control

Further examination &

consider immunotherapy

Or

Surgical turbinate reduction

Rhinologi(Sinusitis)& RA

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