University of SriwijayaFaculty of medicineBlock 4 2010

- SCENARIO 3 -TUTOR GUIDE

What is the most likely diagnosis? What is the most likely etiology for this condition? What is the likely anatomical structures involved in this disorder?

Learning Objectives of Tutorial 2

After completing all of 3 tutorial sessions on the above vignette, the students should be able to:1. Mention terminologies and their clinical significance related to the case.2. Describe anatomy of the respiratory system, the eye, the pharynx and the middle ear.3. Explain the relationship between allergy and infection in nose and paranasal sinus.4. Tell about basic immunology and immunity.5. State the differential diagnosis and rule out the unlikely ones.6. Explain pathogenesis of any symptom and sign found in this case.

Learning issues

To achieve the above objectives, students should study:1. The respiratory system with put more focus on the anatomy of the :

a. Nasal cavity b. Paranasal sinus.

2. The Immunity system.a. The basic concepts of immunology.b. The pathophysiologic basic of allergic conditions.c. The mechanism of infection of tissues following an allergic reaction.

3. Other related systems that might cause headache a. Visual system (disorders of visus, intra ocular pressure, retina etc)b. Auditory system, especially tympanic cavity..c. Digestive system (oral cavity, tonsils, pharynx)

Summary: The girl suffers from persistent headache. It’s likely that she is allergic to cat’s protein which causes allergic reaction in the nasal and sinus mucosa (allergic

rhinitis and allergic sinusistis). Blockage of the sinus ostium causes a reduced air pressure inside the right maxillary and frontal sinus, hence the

headache ensues. Inflammation of the sinus mucosal weakens the local immunity that leads to infection (most likely bacterial).

CLINICAL CORRELATION

Sinusitis is an inflammation of one or more of the six sets of paranasal sinuses, most of which are related to the orbits. Inflammation may be caused by viruses, allergies, and bacterial pathogens. The sinuses are usually sterile cavities that are lined by ciliated mucosa rich in mucous cells, and mucus drains directly into the nasal cavities through small openings, or ostia. Edema of the nasal mucosa can easily occlude these openings and lead to secondary infection. The maxillary sinus is most commonly involved, and sinus pain or pressure sensation is typical. Transillumination of the sinuses that demonstrates opacification may be helpful on physical examination. Radiographs may also be helpful; CT imaging is usually reserved for complicated cases. The recent acquisition of a cat by the patient suggests maxillary and frontal sinusitis caused by an allergy rather than an infectious agent. Oral or topical (spray) decongestants, antihistamines, and/or nasal steroids are often helpful. Antibiotics are not indicated until signs of bacterial infection becomes apparent, so the patient should be instructed to watch for development of fever or an increase in tenderness. Complications include osteomyelitis, ocular cellulitis, and cavernous sinus thrombophlebitis.

APPROACH TO THE BRACHIAL PLEXUSObjectives

1. Describe anatomy of the respiratory system, the eye, the pharynx and the middle ear.2. Explain the relationship between allergy and infection in nose and paranasal sinus.3. Tell about basic immunology and immunity.4. State the differential diagnosis and rule out the unlikely ones.5. Explain pathogenesis of any symptom and sign found in this case.

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Alergine, a 12-year-old girl is brought to the Department of Pediatrics RSMH hospital by her mother due to a

persistent headache she has been complaining for the past 2 weeks. Ten days ago her mother took the girl to

an ophthalmologist to find out the possibility of any eye problem. It appeared that her vision was normal and

there was nothing wrong in the eye and the orbit. The patient states that she has been in good health and that

she received a cat as a birthday present 1 month previously. Just three day ago she gets fever and stuffy nose.

On examination, she has a mild fever, the tympanic membranes appear normal. Her throat is mildly hyperemic

but otherwise looks normal. There is some tenderness of the right cheek and over the right orbit. Her father is

asthmatic while her older brother is allergic to aspirin.

University of SriwijayaFaculty of medicineBlock 4 2010

THE SEVEN JUMPS

Make sure that students follow the seven jumps approach in the discussion.

In Session 1 of tutorialAfter reading the scenario, students should:

1. Clarify all of unknown or poorly understood terminologies and words (phrases or sentences). Let the students identify all the words that they don’t understand or need further clarification. Encourage the students to understand the clinical significance of each word. Give a hint or direction when they fail to identify the following words :

1. Persistent headache2. Ophthalmologist3. Vision 4. Stuffy nose. 5. Mild fever6. Normal tympanic membranes7. Mildly hyperemic throat.8. Tenderness of the right cheek and over the right orbit. 9. Her father is asthmatic10. Allergic to aspirin

2. Identify problems. Problems are anything that’s not normal. Clinical problems are presented as symptoms and signs. For the sake of discussion, problems can be divided into :1) Main problem, 2) contributing problems and 3) chief complain. Treating main problem would get rid off all other problems. In most cases, contributing problems are just side-effects of other problems. Chief complaint is problem that make patient visit a doctor. Include also all other clinical facts such as results of physical (clinical) examination and laboratory workups.

1. Persistent headache (chief complaint).2. Stuffy nose3. Mild fever4. Tenderness over the right cheek and the right orbit.5. Exposure to cat’s protein6. Allergic history in the family

3. Analyze the problems. Direction of the analysis is toward 1) looking for relationship between all the problems identified above, 2) Discussion of patho-physiological aspect of the symptoms and signs (see below).

4. Make a hypothesis. Hypothesis is actually a brief description of the chief complain and the main problems in this patient.

- A 12 year old girl suffers from acute sinusitis secondary to nasal allergy caused by cat’s protein. 5. List learning issues. Make sure the followings are in the students’ list. Encourage them to study the learning issues

the best they can !!!!! Just in case they miss, give suggestion to the following list:1. The anatomy of 1) the respiratory system, 2) the eye, 3) the pharynx and 3) the middle ear.2. The relationship between allergy and infection in nose and paranasal sinus.3. The basic immunology and immunity.4. The pathogenesis of rhinitis allergic and sinusitis5. A brief review of the clinical aspects of rhinitis allergic and sinusitis.

In Session 2After studying the learning issues, students shoud:

6. Share all information they have studied and make a synthesis. 1. Let the students share what they have studied from the learning issues.2. Review in brief brief about :

i. The anatomy of 1) the respiratory system, 2) the eye, 3) the pharynx and 3) the middle ear.ii. The relationship between allergy and infection in nose and paranasal sinus.iii. The basic immunology and immunity.iv. The pathogenesis of rhinitis allergic and sinusitis.

7. Make a report to be presented on the plenary session. Encourage the students to make a report according to all the previous jumps. Make a nice report and share it to others in plenary session.

A short review of the paranasal sinus

The paranasal sinuses are extensions of the nasal cavities into bones of the skull and are named for the bones in which they are located. These spaces are lined with respiratory mucosa, decrease the weight of the skull, and probably assist in humidifying inspired air. The sphenoid sinuses are located within the sphenoid bone, are variable in size and number, and open into the sphenoethmoidal recess.The ethmoidal sinuses consist of a series of sinuses positioned between the medial wall of the orbit and the nasal cavity (at the level of the bridge of the nose). For descriptive purposes, they are divided into anterior, middle, and posterior ethmoidal cells, and each has a separate opening. The posterior ethmoidal cells have their opening in the superior nasal meatus. The middle ethmoidal cells elevate the ethmoid bone in the middle meatus, thus creating the ethmoid bulla on whose surface these cells have their opening. Inferior to the ethmoid bulla is a groove, the semilunar hiatus. The anterior ethmoidal cells open into the anterior portion of the hiatus, called the infundibulum.The largest sinuses are the maxillary and frontal sinuses, and their relatively large openings also drain into the middle meatus. The large maxillary sinus hollows the maxillary bone. The roof of the sinus, which also forms the floor of the orbit, is very thin and at risk in direct trauma to the orbit that causes sudden increases in pressure. Such trauma may cause “blow-out” fractures of the orbital floor. The opening of the maxillary sinus is found in the semilunar hiatus. The frontal sinuses are found in the frontal bone between the inner and outer tables and in the portion that forms the roof of the orbit. It is drained by the frontonasal duct, which opens into the infundibulum, the anterior portion of the semilunar hiatus.

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University of SriwijayaFaculty of medicineBlock 4 2010

Summary of the aspects of RHINOSINUSITIS

1. Pathophysiology1. Initial

1. Mucosal inflammation of paranasal sinuses

2. Sinus ostia irritation and edema

2. Next1. Sinus obstruction and

stasis2. Subsequent sinus infection

2. Epidemiology1. Incidence

1. United States clinic office visits: 1% (in Indonesia …?)2. Lifetime Incidence: 25%

2. Sinuses affected1. Maxillary sinus

1. Most commonly infected in adults2. Frontal sinus

1. Next most commonly infected in adults2. Absent in 10% population and very young children3. Higher risk for intracranial spread

3. Ethmoid sinus1. Most commonly infected in children

4. Sphenoid sinus1. Isolated infection is rare2. Higher risk for intracranial spread

3. Types1. Acute Sinusitis

1. Symptoms as long as 4 weeks2. Subacute Sinusitis

1. Symptoms persist between 4 to 12 weeks3. Chronic Sinusitis

1. Persistent Symptoms beyond 12 weeks4. Recurrent Sinusitis

1. Four or more episodes per year2. Each episode lasts 7 days or more3. Symptom free intervals last greater than 2 months

4. Predisposing Factors1. Environmental Factors

1. Allergens (e.g. pollens, molds, animal dander)2. Nicotine or smoke exposure3. Air pollutants

2. Anatomic abnormalities1. Nasal Polyp s2. Ciliary disorder3. Septal deviation4. Concha bullosa

3. Immune disorder1. AIDS 2. Congenital (IgA or IgG subclas deficiency)3. Post-Transplant4. Chemotherapy 5. Diabetes Mellitus

4. Inflammatory disorder1. Wegener's Granulomatosis 2. Sarcoidosis

5. Recurrent Upper Respiratory Infection6. Mucosal disorder

1. Cystic Fibrosis 2. Allergic Rhinitis and other hyperreactivity3. Nonallergic (Samter's triad)

1. Asthma 2. Nasal Polyp s3. Aspirin sensitivity

5. Etiology:1. Viral (10-15%)

1. Rhinovirus (most common viral Sinusitis cause)2. Influenza 3. Parainfluenza4. Adenovirus

2. Bacterial1. Acute Sinusitis

1. Streptococcus Pneumoniae 2. Haemophilus Influenzae

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University of SriwijayaFaculty of medicineBlock 4 2010

3. Moraxella 4. Streptococcus Pyogenes

2. Chronic Sinusitis 1. Anaerobe s (>50%)

1. Bacteroides 2. Anaerobic Gram Positive Cocci3. Fusobacterium species

2. Other less common causes1. Staphylococcus aureus 2. Hemophilus Influenzae3. Pseudomonas aeruginosa4. Escherichia coli 5. Beta-hemolytic Streptococcus 6. Neisseria causes

3. Fungal (Immunocompromised or Diabetes Mellitus)1. Aspergillus 2. Mucormycosis3. Fungus

6. Symptoms1. Classic Sinus Symptoms

1. Sinus "aching" pain or pressure1. Location

1. Frontal: Frontal Headache2. Maxillary: Mid-face, dental (upper teeth) pain3. Ethmoid: Retro-orbital pain4. Sphenoid: Nonspecific pain radiates top of head

2. Provocative1. Pain increases on bending forward2. Pain increases in late morning3. Pain on mastication

2. Foul Nasal discharge or postnasal discharge1. Purulent yellow or green Nasal discharge2. Discharge color does not indicate bacterial cause3. Discharge for >10 days suggests bacterial Sinusitis

3. Associated Nasal Symptoms1. Decreased sense of smell (Hyposmia or Anosmia)2. Halitosis3. Snoring4. Mouth breathing5. Nasal or hyponasal speech

4. Generalized symptoms1. Fatigue 2. Fever

2. Symptoms not correlating with Sinusitis1. Sore Throat (except with postnasal discharge)2. Sneezing

7. Symptoms: Red Flag (consider immediate ENT referral)1. High Fever over 102.2 F (39 C) or peristent fever2. Visual complaints (e.g. Diplopia)3. Periorbital edema or erythema4. Mental status changes5. Severe facial or dental pain6. Infraorbital hypesthesia

8. Signs1. Nasal Mucosa edema and erythema

1. Contrast with Allergic Rhinitis (pale, boggy mucosa)2. Nasal exam to view pus discharge from lateral wall

1. Instruments1. Nasal speculum (minimal visualization)2. Flexible Nasolaryngoscopy3. Rigid optical scope (Otolaryngology use)

2. Middle Meatus (hiatus semilunaris)1. Drains Maxillary, Frontal, and Anterior Ethmoid2. Consider local Topical Decongestant application

3. Superior Meatus (Rarely discharge is seen)1. Drains posterior ethmoid sinus

3. Turbinates enlarged4. Sinus tenderness to percussion5. Sinus Transillumination in darkened room

1. Frontal and maxillary sinus9. Diagnosis: Findings most suggestive of bacterial cause

1. See Sinusitis Prediction Rules2. Symptoms persist beyond 10 to 14 days

1. Under 10 days, viral Sinusitis predominates2. By day 10, 40% of Sinusitis resolves spontaneously3. 0.5% of viral URIs develop into bacterial Sinusitis

1. Low (1997) CMAJ 156:S1-S14 3. Symptoms worsen after 5-7 days ("double sickening")4. Purulent Nasal discharge

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University of SriwijayaFaculty of medicineBlock 4 2010

5. Maxillary tooth or facial pain (esp. if unilateral)6. Unilateral maxillary sinus tenderness7. References

1. Hickner (2001) Ann Intern Med 134:498-505 2. Lanza (1997) Otolaryngol Head Neck Surg 117:S1-7

10. Labs1. Culture of nasal mucosa

1. Not cost effective or helpful in management2. Does not correlate with sinus mucosa cultures

2. Endoscope directed micro-swab culture1. Swab of hiatus semilunaris2. Protected from nasal contamination3. Accuracy: 80-85% compared with antral puncture

11. Radiology1. Indications for Imaging

1. Complicated Sinusitis2. Chronic or recurrent Sinusitis3. Sinusitis refractory to maximal medical therapy4. Imaging is not needed in routine cases

1. Empiric therapy for 1-2 courses is appropriate2. Sinus XRay (Sinus CT preferred)

1. Single Waters' View XRay is sufficient2. Indication (rarely indicated unless CT not available)

1. Complicated Acute Sinusitis2. Suspected Chronic Sinusitis

3. Sinus CT (gold standard) Indications1. Osteomeatal complex Occlusion2. Chronic Sinusitis 3. Recurrent Sinusitis4. Allergic Fungal Sinusitis

4. Sinus MRI1. No advantage over Sinus CT (and more false positives)2. Indications

1. Suspected neoplasm2. Fungal Sinusitis

12. Complications1. Orbital Cellulitis 2. Meningitis 3. Extradural abscess4. Subdural abscess5. Brain abscess6. Osteomyelitis 7. Cavernous Sinus Thrombosis

13. Management1. See Acute Sinusitis Management

14. Referral Indications1. See Red Flag Symptoms above

15. Reference1. Giebink (1994) Pediatr Infect Dis J 13(suppl 1):S55-8 2. Hadley (1997) Otolaryngol Head Neck Surg 117:S8-S11 3. Lanza (1997) Otolaryngol Head Neck Surg 117:S1-7 4. Osguthorpe (2001) Am Fam Physician 63:69-76 5. Slavin (1991) J Allergy Clin Immunol 88:141-146 6. Williams (1993) JAMA 270:1242-6

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