Crs - Sinusitis Kronik

Identitas pasienNama : Ny. NendahJenis Kelamin : WanitaUsia : 42 tahunPekerjaan : Ibu kantinStatus : MenikahSuku : SundaAgama : IslamAlamat : BaleendahTanggal Pemeriksaan : 1 Juni 2015

Keluhan utamaBau pada hidung sebelah kiri

Anamnesis tambahanPasien datang ke poliklinik THT RSUD Al-Ihsan Bandung dengan keluhan terasa bau pada hidung sebelah kiri sejak 3 tahun yang lalu yang muncul secara tiba-tiba dan hilang timbul. Keluhan disertai sakit kepala dan pilek. Pada hidung sebelah kiri mengeluarkan cairan kental, berwana kuning dan berbau, adanya rasa penuh pada wajah sebelah kiri dan juga terasa nyeri terutama pada saat menunduk seperti bersujud dan jika pasien menekan pipinya. Pasien mengeluhkan adanya hidung tersumbat, ada dahak yang mengalir dari hidung ke mulut, rasa mengganjal di tenggorok dan penurunan penciuman.Pasien datang ke poliklinik THT RSUD Al-Ihsan Bandung dengan keluhan terasa bau pada hidung sebelah kiri sejak 3 tahun yang lalu yang muncul secara tiba-tiba dan hilang timbul. Keluhan disertai sakit kepala dan pilek. Pada hidung sebelah kiri mengeluarkan cairan kental, berwana kuning dan berbau, adanya rasa penuh pada wajah sebelah kiri dan juga terasa nyeri terutama pada saat menunduk seperti bersujud dan jika pasien menekan pipinya. Pasien mengeluhkan adanya hidung tersumbat, ada dahak yang mengalir dari hidung ke mulut, rasa mengganjal di tenggorok dan penurunan penciuman.Pasien menyangkal adanya penurunan pendengaran, telinga kiri terasa penuh, dan mendengung .Pasien tidak mempunyai riwayat asma, alergi terhadap obat, makanan, debu ataupun cuaca dingin, riwayat operasi atau trauma pada sekitar wajah, riwayat hipertensi, penyaki jantung, dan penyakit ginjal. Riwayat pemakaian obat semprot hidung (dekongestan) dalam jangka waktu lama disangkal oleh pasien.Keluarga pasien tidak ada yang mengalami keluhan yang sama seperti pasien. Keluarga pasien juga tidak ada yang mempunyai asma, alergi terhadap obat-obatan, makanan, debu, ataupun cuaca dingin.Riwayat lingkungan pasien mengaku anak dan suaminya merokok di rumah.Pemeriksaan fisikKeadaan Umum: Sakit ringan, kooperatifKesadaran: ComposmentisTinggi Badan: 155 cmBerat Badan: 55 kgTanda-tanda VitalTekanan darah: 110/70 mmHgRespirasi: 21 kali/menitNadi: 74 kali / menitSuhu: 36.00 C

Status generalisKepala:Simetris, tidak ada pembengkakanRambut: tidak rontok, tidak kusamMata: simetris, isokor, ikterik -/-, anemis -/-, allergic shiner -/-Hidung: simetris, septum deviasi -, discharge , allergic salute -, allergic crease -Mulut: simetris, frenulum normal, tdk ada pembesaran tonsil & uvula, lidah bersih, geographic tongue -.Leher : simetris, tidak ada deviasi trakea, tidak ada pembesaran KGB, JVP tdk meningkat, thyroid tidak membesarDada: simetris, napas thoracoabdominalParu: VBS ka=ki, wheezing -/-, ronkhi -/-Jantung: Bunyi jantung regular, murmur -Abdomen: Lembut, datar, timpani, BU +, hepar dan lien tidak terabaExtremitas Atas: simetris, bengkak -/-, sianosis -/-, akral hangat +/+, CR < 2S.Extremitas Bawah: simetris, bengkak -/-, sianosis -/-, akral hangat +/+, CR < 2S.

Status lokalis :a. Telinga

b. Hidung

c. Oral cavity

Tes transluminasi Kesan: Adanya kesuraman sinus maksilaris sinistra44

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Inspeksi:Pada inspeksi sinus frontalis tidak membengkakSinus maksilaris tidak membengkakPalpasi:Nyeri tekan pada sinus maksilaris sinistraMaxillofacialBentuk: simetris Parese nervus cranialis: (-/-)Nyeri tekan (-/+) pada sinus maksilaris sinistraLeherKGB: tidak teraba membesar; pembesaran thyroid ()Massa: (-)DIAGNOSIS KERJASinusitis maksillaris kronik sinistra e.c dentogenUSULAN PEMERIKSAANPemeriksaan darah rutin: leukosit, hitung jenisX-Ray: Waters Hasil pemeriksaan :X-Ray:Ditemukan gambaran perselubungan opaque pada Sinus maksilaris sinistraPenatalaksanaan :ANTIBIOTIKAmoxicillin 500mg 3x1 selama 10 hariMetronidazole 250mg 3x1 selama 10 hariDEKONGESTANPseudoefedrin 60mg 2x1 selama 5 hariANALGESIKAsam mefenamat 500mg 2x1 selama 5 hari bila perluMUKOLITIK Ambroxol 30mg 2x1 selama 5 hariTINDAKAN OPERASIOperasi Caldwell-LucAnatomi sinus Terdapat empat pasang sinus paranasal mulai dari yang terbesar yaitu sinus maksila, sinus frontal, sinus ethmoid dan sinus sfenoid kanan dan kiri. Sinus paranasal merupakan hasil pneumatisasi tulang-tulang kepala sehingga terbentuk rongga di dalam tulang.

EmbriologiSecara embriologik sinus paranasal berasal dari invaginasi mukosa rongga hidung dan perkembangannya dimulai pada fetus usia 3-4 bulan kecuali sinus sfenoid dan frontal. Sinus frontal berkembang dari sinus ethmoid anterior pada anak yang berusia sekitar 8 tahun. Sinus sfenoid mulai mengalami pneumatisasi antara usia 8-10 tahun dan berasal dari rongga hidung bagian posterosuperior

Sinus maxillasinus paranasal terbesar. 6-8 ml saat lahir dewasa 15 ml. Sinus ini berbentuk segitiga dan dibatasi di bagian anterior oleh permukaan fasial os maksila (fosa canina), bagian posterior permukaan infratemporal maksila, dinding medialnya dinding lateral rongga hidung, dinding superiornya dasar orbita dan bagian inferiornya adalah prosessus alveolaris serta palatum. Ostium sinus maksila berada di sebelah superior dinding medial sinus dan bermuara ke hiatus semilunaris melalui infundibulum ethmoid.

Secara klinis yang perlu diperhatikan dari sinus maksila adalah : 1) dasar sinus maksila sangat berdekatan dengan akar gigi rahang atas yaitu premolar (P1, P2) molar (M1, M2) kadang-kadang gigi taring (C) atau gigi molar M3. Infeksi gigi sinusitis2) sinusitis maksila dapat menimbulkan komplikasi ke orbita 3) ostium sinus maksila terletak lebih tinggi dari dasar sinus sehingga drainase kurang baik. Sinus frontal :Bulan ke empat sel-sel resesus frontal atau dari sel-sel infundibulum ethmoid. Sinus frontal kanan dan kiri biasanya tidak simetris, dipisahkan oleh sekat berupa tulang yang relatif tipis dari orbita dan fosa cerebri anterior sehingga infeksi dari sinus frontal mudah menyebar ke daerah ini. Kurang lebih 15% orang dewasa hanya mempunyai satu sinus frontal dan kurang lebih 5% sinus frontalnya tidak berkembang. berlekuk-lekuk, tidak lekuk-lekuk ~ infeksi. lebar 2,4 cm tinggi 2,8 cm dan dalamnya 2 cm.Sinus ethmoid :fokus infeksi bagi sinus-sinus lainnya. ukuran dari anterior ke posterior 4-5 cm, tinggi 2,4 cm dan lebarnya 0,5 cm di bagian anterior serta 1,5 cm di bagian posterior. sel-sel menyerupai sarang tawon. Sel-sel sinus ethmoid anterior biasanya lebih kecil dan lebih padat dibandingkan di bagian posterior sinus. Berdasarkan letaknya sinus ethmoid dibagi menjadi sinus ethmoid anterior meatus media dan sinus ethmoid posterior meatus superior. Sel etmoid terbesar disebut bula etmoid. Terdapat infundibulum (penyempitan) pada etmoid anterior tempat muaranya ostium sinus maksila. Dinding lateral sinus adalah lamina papirasea yang sangat tipis dan membatasi sinus ethmoid dari rongga orbita. Bagian belakang sinus ethmoid posterior berbatasan dengan sinus sfenoid.

Sinus sphenoid Sinus sfenoid terletak dalam os sfenoid yang terpisah menjadi dua oleh sekat septum intersfenoid. tinggi 2 cm, dalamnya 2,3 cm dan lebarnya 1,7 cm. 5-7, 5 ml. Sebelah superior dibatasi fossa cerebri media dan kelenjar hipofise, sebelah inferior atap nasofaring, lateralnya dibatasi sinus cavernosus dan arteri carotis interna (sering tanpak sebagai indentasi) dan sebelah posterior terdapat fossa cerebri posterior di daerah pons.Kompleks ostio-meatalPada sepertiga tengah dinding lateal hidung yaitu di meatus medius, ada muara-muara saluran dari sunis maksila, sinus frontal dan sinus etmoid anterior. Daerah ini rumit dan sempit, dan dinamakan kompleks ostio-meatal (KOM)

Sistem mukosiliariSeperti pada mukosa hidung, di dalam sinus juga terdapat mukosa bersilia dan palut lendir diatasnya. Di dalam sinus silia bergerak secara teratur untuk mengalirkan lendir menuju ostium alamiahnya mengikuti jalur-jalur yang sudah tertentu polanya.HistologiEpitel respirasi (epitel bertingkat silidris bersilia) yang lebih tipis yang mengandung sedikit sel gobletLamina propria mengandung beberapa kelenjar kecil dan berhubungna langsung dengan periosteum dibawahnyaFisiologi Sebagai pengatur kondisi udara (air conditoning) Sebagai penahan suhu (Thermal Insulators)Membantu keseimbangan kepala, karena mengurangi berat tulang mukaMembantu resonansi suaraMembantu produksi mucus

SinusitisEtiologiTerdapat 2 faktor yaitu infeksius dan nonifeksius yang dapat memberikan kontribusi dalam terjadinya obstruksi akut ostia sinus atau gangguan pengeluaran cairan oleh silia, yang akhirnya menyebabkan sinusitis. Penyebab nonifeksius antara lain adalah rinitis alergika, barotrauma, atau iritan kimia. Penyakit seperti tumor nasal atau tumor sinus (squamous cell carcinoma), dan juga penyakit granulomatus (Wegeners granulomatosis atau rhinoskleroma) juga dapat menyebabkan obstruksi ostia sinus, sedangkan konsisi yang menyebabkan perubahan kandungan sekret mukus (fibrosis kistik) dapat menyebabkan sinusitis dengan mengganggu pengeluaran mukus. Pada dasarnya patofisiologi dari sinusitis dipengaruhi oleh 3 faktor yaitu obstruksi drainase sinus (sinus ostia), kerusakan pada silia, dan kuantitas dan kualitas mukosaFaktor predisposisi ISPA akibat virus Rhinitis terutama rhinitis alergi Rhinitis hormonal pada ibu hamil Polip hidung Kelainan anatomi seperti deviasi septum atau hipertrofi konka Sumbatan kompleks ostio-meatal (KOM) Infeksi tonsil Infeksi gigi Kelainan imunologi Lingkungan berpolusi Udara dingin dan kebiasaan merokok

Patogenesis dan patofisiologiAdanya sumbatan pada ostium sinusRetensi seksresi mukus, tekanan sinus menjadi negatif dan kurangnya parsial oksigenMenjadi area patogen untuk mempermudah perkembangan mikroorganisme (bakteri,virus, jamur)Bakteri bermultiplikasi dan menjadi purulen

TANDA DAN GEJALA Nasal obstruction, blockage, congestion, stuffiness Nasal discharge (of any character from thin to thick and from clear to purulent) Postnasal drip Facial fullness, discomfort, pain, and headache (more with nasal polyposis) Chronic unproductive cough (primarily in children) Hyposmia or anosmia (more with nasal polyposis) Sore throat Fetid breath Malaise Easy fatigability Anorexia Exacerbation of asthma Dental pain (upper teeth) Visual disturbances Sneezing Stuffy ears Unpleasant taste Fever of unknown origin

DIAGNOSIS

Physical ExaminationPhysical examination in patients with chronic sinusitis may reveal various findings. It should include a complete head and neck examination (lymphadenopathy) to confirm the diagnosis and to rule out more serious disorders.Sinus palpation is performed to evaluate tenderness or swelling. Pain or tenderness on palpation over frontal or maxillary sinuses may be noted. Transillumination of maxillary or frontal sinuses may be useful; it lacks sensitivity but may have value in experienced hands.An oral cavity and oropharynx examination is used to evaluate the integrity of the palate and the condition of dentition and to look for evidence of postnasal drip. Oropharyngeal erythema and purulent secretions may be noted. Dental caries may be present.Anterior rhinoscopy, with the use of a nasal speculum, is used to evaluate the condition of the nasal mucosa and to look for purulent drainage or evidence of polyps or other nasal masses. Other contributing factors to CRS that can be evaluated are nasal septal deviation and turbinate hypertrophy. The nasal examination should be carried out both before and after the use of a topical decongestant.The nasal examination can be supplemented with the use of nasal endoscopy (if available). Endoscopic (rhinoscopic) examination findings include the following: Nasal mucosal erythema, edema Purulent secretions Nasal obstruction due to deviated nasal septum or hypertrophied turbinates Nasal polypsAn endoscopic view of the nasal cavity can be seen below.Endoscopic view right nasal cavity; lacrimal bone (L), uncinate process (U), ethmoid bulla (B), middle turbinate (MT), nasal septum (S).Ear examination for the presence of middle ear fluid that may be the sign of a mass in the nasopharynx is indicated.Ocular examination for spread of disease to the orbit and function of ocular musculature is indicated. Ophthalmic manifestations include the following: Conjunctival congestion Lacrimation Proptosis, extraocular muscle palsies, and visual disturbances (when complicated by orbital extension)Laryngeal examination is used to look for other confounding upper airway pathology including laryngeal-pharyngeal reflux (LPR). Lung examination is performed to determine if coexisting lower airway disease is present.Cranial nerve examination is performed to look for underlying sinus malignancy or neurological disorder.Manifestations of fungal sinusitisFungal sinusitis can manifest in different ways.[19]Unlike acute invasive fungal sinusitis, which is observed in patients who are immunosuppressed or who have diabetes, chronic fungal sinusitis is usually observed in immunocompetent patients. Mycetomas or fungus balls may be asymptomatic or may manifest as chronic sinusitis. Allergic fungal sinusitis usually manifests as nasal polyps and allergic sinusitis. Fungal elements in the sinuses are the inciting allergens.

In 1996, the American Academy of Otolaryngology-Head & Neck Surgery convened a multidisciplinary Rhinosinusitis Task Force (RTF). This group defined adult rhinosinusitis diagnostic criteria.[3]These 1996 diagnostic criteria required 2 or more major factors or 1 major factor and 2 minor factors for the diagnosis of rhinosinusitis.Major factors included facial pain or pressure, nasal obstruction or blockage, nasal discharge or purulence or discolored postnasal discharge, hyposmia or anosmia, purulence in nasal cavity, and fever (for acute rhinosinusitis only).Minor factors were defined as headache, fever (for CRS), halitosis, fatigue, dental pain, cough, and ear pain, pressure, or fullness. Of note, facial pain requires another major factor associated with it for diagnosis (facial pain plus 2 minor factors is not deemed sufficient for diagnosis of rhinosinusitis).In 2003, the RTFs definition was amended to require confirmatory radiographic or nasal endoscopic or physical examination findings in addition to suggestive history.[4]The 2003 diagnostic criteria for CRS require the above criteria for longer than 12 weeks or more than 12 weeks of physical findings. In addition, one of the following signs of inflammation must be present: Discolored nasal drainage from the nasal passages, nasal polyps, or polypoid swelling as identified on physical examination with anterior rhinoscopy after decongestion or nasal endoscopy Edema or erythema of the middle meatus or ethmoid bulla on nasal endoscopy Generalized or localized erythema, edema, or granulation tissue (If the middle meatus or ethmoid bulla is not involved, radiologic imaging is required to confirm a diagnosis.)Imaging modalities confirming the diagnosis include the following: Computed tomography (CT) scanning demonstrating isolated or diffuse mucosal thickening, bone changes, or air-fluid levelsOR Plain sinus radiography revealing air-fluid levels or greater than 5 mm of opacification of one or more sinuses Magnetic resonance imaging (MRI) not recommended for routine diagnosis because of its excessive sensitivity and lack of specificityIn general, plain radiography has low sensitivity and specificity. CT scanning is considered the imaging standard for evaluation of chronic sinusitis.[20]The latest executive summary on adult sinusitis has altered the definition for CRS to read 12 weeks or longer of 2 or more of the following symptoms:[21] Anterior or posterior mucopurulent drainage Nasal obstruction Facial-pain-pressure-fullness Decreased sense of smellIn addition, inflammation must be documented by demonstrating one of the following: Purulent mucus or edema in the middle meatus or ethmoid region Polyps in the nasal cavity or middle meatus Imaging showing inflammation of the paranasal sinusesThis is in contrast to recurrent acute sinusitis, which is present when 4 or more episodes per year of acute bacterial rhinosinusitis without signs and symptoms of rhinosinusitis between episodes.

DDProblems to be considered include the following: Temporomandibular joint syndrome Asthma Other chronic rhinitis Nasal and sinus cavity tumors Facial pain and headache attributable to other causes Nasal polyp Dental infection Periodontal abscess Antral-choanal polyp Inverting papilloma Aspirin/nonsteroidal anti-inflammatory drug sensitivity Chronic headache of other etiologyDifferential Diagnoses Allergic Fungal Sinusitis Cystic Fibrosis Fever of Unknown Origin Foreign Bodies of the Airway Gastroesophageal Reflux Disease Juvenile Nasopharyngeal Angiofibroma Malignant Nasopharyngeal Tumors Malignant Tumors of the Nasal Cavity Malignant Tumors of the Sinuses Nonallergic Rhinitis Olfaction disorders Pain due to other causes (migraine, tension headaches, and cluster headaches, and facial pain syndromes) Rhinitis, Allergic Rhinocerebral Mucormycosis Sinusitis Sinusitis, Acute Sinusitis, Acute, Medical Treatment Sinusitis, Chronic, Medical Treatment Sinusitis, Fungal Skull Base, Benign Tumors Turbinate Dysfunction

Sinusitis KronikSinusitis kronis berbeda dari sinusitis akut dalam berbagai aspek, umumnya sukar disembuhkan dengan pengobatan medikamentosa saja. Harus dicari faktor penyebab dan faktor predisposisinya.Polusi bahan kimia menyebabkan silia rusak, sehingga terjadi perubahan mukosa hidung dapat juga disebabkan oleh alergi dan defisiensi imunologik. Perubahan mukosa hidung akan mempermudah terjadinya infeksi dan infeksi menjadi kronis apabila pengobatan pada sinusitis akut tidak sempurna.Adanya infeksi akan menyebabkan edema konka, sehingga drenase sekret akan terganggu. Drenase sekret yang terganggu dapat menyebabkan silia rusak dan seterusnya.

Gejala SubyektifGejala subyekif sangat bervariasi dari ringan sampai berat, terdiri dari:Gejala hidung dan nasofaring, berupa sekret di hidung dan sekret pasca nasal drip (post nasal drip).Gejala faring, yaitu rasa tidak nyaman dan gatal di tenggorok.Gejala telinga, berupa pendengaran terganggu oleh karena tersumbatnya tuba Eustachius.Adanya nyeri/sakit kepala.Gejala mata, oleh karena penjalaran infeksi melalui duktus naso-lakrimalis.Gejala saluran napas berupa batuk dan kadang-kadang terdapat komplikasi di paru, beruoa bronchitis atau bronkietaksis atau asma bronchial, sehingga terjadi penyakit sinobronkitis.Gejala di saluran cerna, oleh karena mukopus yang tertelan dapat menyebabkan gastroenteritis,`sering terjadi pada anak.

Kadang-kadang gejala sangat ringan hanya terdapat sekret di nasofaring yang meengganggu pasien. Sekret pasca nasal yang terus-menerus akan mengakibatkan batuk kronik.Nyeri kepala pada sinusitis kronis biasanya terasa pada pagi hari dan akan berkurang atau hilang setelah siang hari. Penyebabnya belum diketahui dengan pasti, tetapi mungkin karena pada malam hari terjadi penimbunan ingus dalam rongga hidung dan sinus serta adamya stasis vena.

Gejala obyektifPada sinusitis kronis, temuan pemeriksaan klinis tidak seberat sinusitis akut dan tidak terdapat pembengkakan pada wajah. Pada rinoskopi anterior dapat ditemukan sekret kental purulen dari meatus medius atau meatus superior. Pada rinoskopi posterior tampak sekret purulen di nasofaring atau turun ke tenggorok.Pemeriksaan mikrobiologikBiasanya merupakan infeksi campuran oleh bermacam-macam mikroba, seperti kuman aerobS. aureus,S. viridians,H. Influenzaedan kuman anaerob Peptostreptokokus dan Fusobakterium.

Diagnosis sinusitis kronikDibuat berdasarkan anamnesis yang cermat, pemeriksaan rinoskopi anterior dan posterior serta pemeriksaan penunjang berupa transiluminasi untuk sinus maksila dan sinus frontal, pemeriksaan radiologik, pungsi sinus maksila, sinoskopi sinus maksila, pemeriksaan histopatologik dari jaringan yang diambil pada waktu dilakukan sinoskopi, pemeriksaan meatus medius dan meatus superior dengan menggunakan naso-endoskopi dan pemeriksaan CT-scan.

TerapiPada sinusitis kronis perlu diberikan terapi antibiotikuntuk mengatasi infeksinya dan obat-obatan simtomatis lainnya. Antibiotik diberikan selama sekurang-kurangnya 2 minggu. Selain itu dapat juga dibantu dengan diatermi gelombang pendek selama 10 hari di daerah sinus yang sakit.Tindakan lain yang dapat dilakukan ialah tindakan untuk membantu memperbaiki drenase dan pembersihan sekret dan sinus yang sakit.Untuk sinusitis maksila dilakukan pungsi dan irigasi sinus, sedangkan untuk sinusitis etmoid, frontal atau sphenoid dilakukan tindakan pencucian Proetz.Irigasi dan pencucian sinus ini dilakukan 2 kali dalam seminggu. Bila setelah 5-6 kali tidak ada perbaikan dan klinis masih tetap banyak sekret purulen, berarti mukosa sinus sudah tidak dapat kembali normal (perubahanirreversible), maka perlu dilakukan operasi radikal.Untuk mengetahui perubahan mukosa masihreversibleatau tidak, dapat juga dilakukan dengan pemeriksaan sinoskopi, yaitu melihat antrum (sinus maksila) secara langsung dengan menggunakan endoskop.Komplikasi SinusitisCT-Scan penting dilakukan dalam menjelaskan derajat penyakit sinus dan derajat infeksi di luar sinus, pada orbita, jaringan lunak dan kranium. Pemeriksaan ini harus rutin dilakukan pada sinusitis refrakter, kronis atau berkomplikasi.1.Komplikasi orbitaSinusitis ethmoidalis merupakan penyebab komplikasi pada orbita yang tersering. Pembengkakan orbita dapat merupakan manifestasi ethmoidalis akut, namun sinus frontalis dan sinus maksilaris juga terletak di dekat orbita dan dapat menimbulkan infeksi isi orbita.Terdapat lima tahapan :Peradangan atau reaksi edema yang ringan. Terjadi pada isi orbita akibat infeksi sinus ethmoidalis didekatnya. Keadaan ini terutama ditemukan pada anak, karena lamina papirasea yang memisahkan orbita dan sinus ethmoidalis sering kali merekah pada kelompok umur ini.Selulitis orbita, edema bersifat difus dan bakteri telah secara aktif menginvasi isi orbita namun pus belum terbentuk.Abses subperiosteal, pus terkumpul diantara periorbita dan dinding tulang orbita menyebabkan proptosis dan kemosis.Abses orbita, pus telah menembus periosteum dan bercampur dengan isi orbita. Tahap ini disertai dengan gejala sisa neuritis optik dan kebutaan unilateral yang lebih serius. Keterbatasan gerak otot ekstraokular mata yang tersering dan kemosis konjungtiva merupakan tanda khas abses orbita, juga proptosis yang makin bertambah.Trombosis sinus kavernosus, merupakan akibat penyebaran bakteri melalui saluran vena kedalam sinus kavernosus, kemudian terbentuk suatu tromboflebitis septik.Secara patognomonik, trombosis sinus kavernosus terdiri dari :a.Oftalmoplegia.b.Kemosis konjungtiva.c.Gangguan penglihatan yang berat.Tanda-tanda meningitis oleh karena letak sinus kavernosus yang berdekatan dengan saraf kranial II, III, IV dan VI, serta berdekatan juga dengan otak.

2.MukokelMukokel adalah suatu kista yang mengandung mukus yang timbul dalam sinus, kista ini paling sering ditemukan pada sinus maksilaris, sering disebut sebagai kista retensi mukus dan biasanya tidak berbahaya.Dalam sinus frontalis, ethmoidalis dan sfenoidalis, kista ini dapat membesar dan melalui atrofi tekanan mengikis struktur sekitarnya. Kista ini dapat bermanifestasi sebagai pembengkakan pada dahi atau fenestra nasalis dan dapat menggeser mata ke lateral. Dalam sinus sfenoidalis, kista dapat menimbulkan diplopia dan gangguan penglihatan dengan menekan saraf didekatnya.Piokel adalah mukokel terinfeksi, gejala piokel hampir sama dengan mukokel meskipun lebih akut dan lebih berat.Prinsip terapi adalah eksplorasi sinus secara bedah untuk mengangkat semua mukosa yang terinfeksi dan memastikan drainase yang baik atau obliterasi sinus.

3.Komplikasi Intra KranialMeningitis akut, salah satu komplikasi sinusitis yang terberat adalah meningitis akut, infeksi dari sinus paranasalis dapat menyebar sepanjang saluran vena atau langsung dari sinus yang berdekatan, seperti lewat dinding posterior sinus frontalis atau melalui lamina kribriformis di dekat sistem sel udara ethmoidalis.Abses dural adalah kumpulan pus diantara dura dan tabula interna kranium, sering kali mengikuti sinusitis frontalis. Proses ini timbul lambat, sehingga pasien hanya mengeluh nyeri kepala dan sebelum pus yang terkumpul mampu menimbulkan tekanan intra kranial.Abses subdural adalah kumpulan pus diantara duramater dan arachnoid atau permukaan otak. Gejala yang timbul sama dengan abses dura.Abses otak, setelah sistem vena, dapat mukoperiosteum sinus terinfeksi, maka dapat terjadi perluasan metastatik secara hematogen ke dalam otak. Terapi komplikasi intra kranial ini adalah antibiotik yang intensif, drainase secara bedah pada ruangan yang mengalami abses dan pencegahan penyebaran infeksi.

4.Osteomielitis dan abses subperiostealPenyebab tersering osteomielitis dan abses subperiosteal pada tulang frontalis adalah infeksi sinus frontalis. Nyeri tekan dahi setempat sangat berat. Gejala sistemik berupa malaise, demam dan menggigil

WORKUPApproach ConsiderationsAlways consider serious underlying conditions, such as tumors and immunodeficiency states, in the workup. In general, plain radiography has low sensitivity and specificity. CT scanning is considered the imaging standard for evaluation of chronic sinusitis. Routine blood cell counts and sedimentation rates are generally unhelpful; however, these may be elevated in patients with fever.The cornerstone in the diagnostic workup of chronic sinusitis is the radiologic examination. Nasal endoscopy is recommended in most cases prior to obtaining imaging because it demonstrates the condition of the nasal mucosa and evaluates for purulent drainage.Radiographic findings in individuals with chronic sinusitis may demonstrate osteoblastic response in the affected sinus walls, mucoperiosteal thickening, opacification of sinus cavity, and even reduction of cavity size. Younger children with persistent respiratory symptoms probably have significant abnormalities that are observable on sinus radiographs. These radiographs provide noninvasive and rapid evaluation of the lower third of the nasal cavity and of the maxillary, frontal, sphenoid, and posterior ethmoid sinuses. Unfortunately, these views provide only limited information about anterior ethmoid anatomy and may be misleading in soft-tissue inflammatory disease; hence, more physicians are using CT for preoperative evaluation and MRI for excluding orbital and intracranial extension.[20]For more information, see the Medscape Reference articleImaging in Sinusitis.Lund-Mackay scale for evaluation of imagesVarious staging systems have been proposed; however, no one system is accepted as the standard for use in chronic rhinosinusitis (CRS). Many studies use the Lund-Mackay scale to evaluate radiographic images. This scale grades the right and left sides independently, looking at the maxillary, anterior ethmoids, posterior ethmoids, sphenoid, and frontal sinuses, as well as the ostiomeatal complex. Each sinus is scored a 0 (no abnormality), 1 (partial opacification), or 2 (total opacification), while the ostiomeatal complex is scored either a 0 or 2 (for presence or absence of disease). Scores range from 0-24.CulturesEstablishing the presence of sinus infection requires obtaining bacterial and fungal cultures. These can be obtained directly from the sinus cavity (by maxillary sinus tap or during surgery) or endoscopically from the ostia. Studies of chronic sinusitis have demonstrated no correlation between nasal flora and culture from the sinuses. Nasal swab cultures have therefore no diagnostic value. In severe cases, blood cultures, including fungal blood cultures, may be helpful.Maxillary sinus tapTraditionally, maxillary sinus tap via inferior meatal puncture was performed for sinus culture. Many otolaryngologists have moved away from maxillary sinus tap because of the discomfort of the procedure and the understanding that a culture of an organism from the middle meatus may be more accurate to determine the bacteria involved in the disease process.Endoscopically directed middle meatal cultureRecent literature has supported the use of endoscopically directed culture of the middle meatus (the primary drainage system of the anterior ethmoid, maxillary, and frontal sinuses) with the use of either a suction trap or a swab. Endoscopically directed middle meatal cultures had a sensitivity of 80.9% and a specificity of 90.5% in a recent meta-analysis.[22]Imaging StudiesPlain radiography may show mucosal thickenings or sinus opacities. However, it is not adequate to diagnose chronic rhinosinusitis because abnormalities detected on plain films are not sensitive or specific for sinusitis. Air fluid levels are uncommon in chronic sinusitis. Ethmoid sinuses and the ostiomeatal complex are not visualized well on plain sinus radiography. For more information, see the Medscape Reference articleImaging in Sinusitis.Multiplanar sinus CT scan is the preferred imaging technique for evaluating chronic rhinosinusitis. Sinusitis is characterized by the presence of sinus mucosal thickening, sinus ostial obstruction, and sinus opacification. Other findings include polyps, mucoceles, and bony changes due to chronic rhinosinusitis (sclerosis, septations, erosions, and bowing).Contrast-enhanced CT scanning is the current radiologic criterion standard for the evaluation of sinus diseases, although performing CT scanning in all patients with chronic sinus disease may be prohibitively expensive or medically unnecessary. CT scans are usually indicated after failure of maximal medical therapy, before surgical planning for evaluation of suspected complications, and when a neoplasm is a possibility. CT scan combined with endoscopic examination helps the surgeon to make operative decisions.Coronal CT scan of the sinus correlates best with the surgical approach, permitting visualization of the anatomy of the nasal cavity, ostiomeatal complex, sinus cavities, and surrounding structures such as the orbit, cribriform plate, and optic canal. Anatomic obstructions at the ostiomeatal complex and dental pathologies are visualized well. Specific entities in the sinus cavity, such as aspergilloma, are also visualized well.Most centers now offer limited sinus CT scans that consist of 5-12 coronal cuts. These limited or screening CT scans cost about the same as a plain radiography but provide more information.Magnetic resonance imaging (MRI) is generally reserved only for complex cases. Soft-tissue contrast is better with MRI. Neoplasms, orbital and intracranial complications, and fungal sinusitis can be better evaluated with MRI.BiopsyBiopsy samples from the maxillary sinus mucosa of patients with chronic sinusitis show basement membrane thickening, atypical gland formation, goblet cell hyperplasia, mononuclear cell infiltration, and subepithelial edema. The mononuclear cell infiltrate often predominantly demonstrates neutrophils in acute disease and eosinophils in chronic disease. Rarely, squamous cell metaplasia may be seen.Brush biopsy or turbinate biopsyEvaluation of cilia function with a brush biopsy or turbinate biopsy can be considered in cases of presumed cilia dysfunction.Endoscopic biopsySpecimens obtained from sinus openings via endoscopy correlate well with those obtained with endoscopic surgery or sinus puncture. These should be processed for cultivation of aerobic and anaerobic bacteria, as well as fungi. Specimens evaluated for anaerobic bacteria should be sent in proper transport media. Liquid specimens are preferred to swab specimens.Other TestsEnvironmental allergen evaluation should be considered. Radioallergosorbent assay test (RAST) or skin testing for allergens may play an important role in treating patients with chronic rhinosinusitis (CRS) and confounding allergies. Perform allergy testing if allergy is thought to be the underlying cause.Associated immune deficiency is evaluated with serum immunoglobulin and IgG subclass determination, antibody response to specific antigens, and HIV antibody testing (when indicated).A sweat test for cystic fibrosis should be considered in all children with nasal polyposis and CRS.Total immunoglobulin E (IgE) levels, as well as the degree of staining of IgE in sinus epithelium and subepithelium, can be tested and may be helpful to evaluate for allergic fungal sinusitis.[23]

TREATMENTThe goals of medical therapy for CRS are to reduce mucosal edema, promote sinus drainage, and eradicate infections that may be present. This often requires a combination of topical or oral glucocorticoids, antibiotics, and nasal saline irrigation. If these measures fail, the patient should be referred to an otolaryngologist for consideration of sinus surgery. The role of bacteria in the pathogenesis of chronic sinusitis remains debatable; however, an early diagnosis and intensive treatment with oral antibiotics, topical nasal steroids, decongestants, and saline nasal sprays results in symptom relief in a significant number of patients, many of whom can be cured. When medical therapy is unsuccessful, refer the patient for surgical evaluation.Tujuan terapi sinusitis kronik adalah untuk reduksi edema mukosa, drainase sinus dan eradikasi infeksi bila ada. Biasanya memerlukan kombinasi obat kortikosteroid, antibiotic dan irigasi nasal. Bila gagal maka akan dipertimbangkan untuk operasi sinus.Inpatient treatment of chronic sinusitis is indicated for patients with orbital and intracranial complications. Immunosuppressed patients and pediatric patients with chronic sinusitis may need inpatient care, depending on the severity of the disease.Control of Predisposing FactorsBecause chronic sinusitis has many risk factors and potential etiologies, apply a combined approach to control or modify these factors in the management of chronic sinusitis.Viral upper respiratory tract infectionsReduce viral exposures by improved personal hygiene. The roles of zinc and vitamin C in the prevention of viral upper respiratory tract infection are controversial. On June 16, 2009, the US Food and Drug Administration (FDA) issued a public health advisory and notified consumers and health care providers to discontinue the use of intranasal zinc products.[24]The intranasal zinc products (Zicam Nasal Gel/Nasal Swab; Matrixx Initiatives) are herbal cold remedies that claim to reduce the duration and severity of cold symptoms and are sold without a prescription. The FDA received more than 130 reports of anosmia (ie, an inability to detect odors) associated with intranasal zinc. Many of the reports described the loss of smell with the first dose.Environmental and allergic factorsEnvironmental factors and/or allergic factors may predispose some individuals to chronic sinusitis. Reduce exposure to dust, molds, cigarette smoke, and other environmental chemical irritants. For patients with confounding nasal allergy, other antiallergy therapies, including either oral or topical antihistamines, cromolyn, topical steroids, and immunotherapy, may reduce recurrences and symptoms of allergic rhinitis.Smoking cessation likely plays a large role in the success of both medical and surgical treatments because tobacco products act as an irritant to normal nasal mucosa and cilia function.Gastroesophageal reflux diseasePatients with adult chronic sinusitis may benefit from control of gastroesophageal reflux disease (GERD), which has increasingly been implicated in causing or exacerbating respiratory ailments such as asthma and chronic sinusitis. The exact relationships and mechanisms are presently a matter of speculation.ImmunodeficiencyAppropriate control of various congenital and acquired immunodeficiency states is necessary to cure chronic sinusitis.AsthmaEspecially for patients with co-existing asthma, leukotriene inhibitors may play a role.Symptomatic TreatmentSymptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics.Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity.Initial oral steroid therapy followed by topical steroid therapy was found to be more effective than topical steroid therapy alone in decreasing polyp size and improving olfaction in patients with chronic rhinosinusitis (CRS) with at least moderate nasal polyposis.[25]Catalano et al evaluated balloon dilation for the treatment of chronic frontal sinusitis in 20 patients with advanced sinus disease in whom medical therapy had failed and therefore required operative intervention. Preoperative and postoperative CT scans were compared. There were no significant complications from balloon dilation, and there was significant improvement in patients with certain subsets of CRS.[26]To see complete information on Balloon Sinuplasty, please go to the main article by clickinghere.Antimicrobial TherapyAntibiotic adekuat biasanya 3-4 minggu. Pengobatan harus melingkupi antibiotic aerob dan anaerob. Kombinasi amoksisilin dengan asam klavulanat, metronidazole dengan makrolid atau sefalosporin atau kuinolon. An adequate antibiotic trial in CRS usually consists of a minimum of 3-4 weeks of treatment, preferably culture directed. Oral antibiotic regimens are generally used to treat chronic sinusitis, since this condition is primarily treated in an outpatient setting. For resistant cases, there may be a role for intravenous antibiotic therapy.Initial choice of the appropriate antimicrobial(s) is usually empiric. Sinus cultures are not generally obtained for community-acquired infections unless empiric therapy fails to elicit a response. The agent(s) chosen should be effective against the most likely bacterial etiologies, including both aerobic and anaerobic pathogens. The likelihood of involvement by beta-lactamaseproducing organisms should be considered. If methicillin-resistantStaphylococcus aureus(MRSA) is a possible pathogen, coverage for this should be included. History of drug allergies (if any) and cost of therapy should be taken into account as well. In addition, if the patient has received antibiotics during the preceding 3 months, a different class of antibiotics should be used.Therapeutic regimens include the combination of a penicillin (eg, amoxicillin) plus a beta-lactamase inhibitor (eg, clavulanic acid), a combination of metronidazole plus a macrolide or a second- or third-generation cephalosporin, and the newer quinolones (eg, moxifloxacin). All of these agents (or similar ones) are available in oral and parenteral forms. Other effective antimicrobials are available only in parenteral form (eg, cefoxitin, cefotetan). If aerobic gram-negative organisms (eg,Pseudomonas aeruginosa) are involved, parenteral therapy with an aminoglycoside, a fourth-generation cephalosporin (cefepime or ceftazidime), or oral or parenteral treatment with a fluoroquinolone (only in postpubertal patients) is added. Parenteral therapy with a carbapenem (ie, imipenem, meropenem) is more expensive but provides coverage for most potential pathogens, both anaerobes and aerobes.Agents that provide coverage for MRSA should be administered. Some options include tetracyclines, trimethoprim-sulfamethoxazole or linezolid, which are added to other regimens that cover anaerobes. Parenteral antimicrobials effective against MRSA include vancomycin, linezolid, and daptomycin.Ferguson et al performed a prospective observational study of 125 adults with classic symptoms of chronic rhinosinusitis who underwent nasal endoscopy and sinus CT. Severe symptoms occurred more often in younger patients with normal CT scans of the sinus than in those with positive CT findings. Improvement in response to antibiotics was similar for patients with positive CT findings and those with normal CT scans. The authors concluded that most symptoms considered to be typical for chronic rhinosinusitis proved to be nonspecific, and they suggest that objective evidence of mucopurulence assessed by endoscopy or CT should be obtained if a prolonged course of antibiotics is being considered.[27]It is useful to tailor therapy to the clinical type of CRS.[28]CRS without nasal polyps is treated with prednisone 20-40 mg daily tapered over 10 days plus an intranasal steroid. Antibiotic therapy is often required for up to 6 weeks or longer and should not be discontinued until the patient is asymptomatic. Discontinuation of antimicrobial therapy prior to complete resolution increases the likelihood of relapse.Nebulized antibiotics and antifungal agents be used in refractory cases, especially in patients who have undergone sinus surgery and as a means to avoid prolonged therapy with intravenous antibiotics. Further studies need to be done to establish their role in treating CRS.[29]In individuals with CRS with nasal polyps, the major intervention is to relieve the obstruction to sinus drainage by reducing or eliminating the polyp. This is achieved primarily with glucocorticosteroids, both systemically and intranasally. Antileukotriene agents can be adjunctive to the effect of the steroids, especially in patients with asthma or an allergy to aspirin.[30]There is a high rate ofS aureuscolonization of the sinus mucosa in CRS with nasal polyps. Three weeks of doxycycline therapy has been demonstrated to reduce polyp size, possibly because of the anti-inflammatory properties of the tetracyclines, as well as their anti-staphylococcal effects.[31]Failure to relieve the polyposis obstruction with medical therapy is an indication for a surgical approach.Fungal CRP is primarily treated with appropriate surgery (see below).Surgical CareFunctional Endoscopic Sinus SurgerySurgical care is used as an adjunct to medical treatment in some cases. Surgical care is usually reserved for cases that are refractory to medical treatment and for patients with anatomic obstruction. Preoperative CT findings prior to sinus surgery may be poor predictors of surgical outcomes.[32]The goal in surgical treatment is to reestablish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system. Surgery strives to restore the functional integrity of the inflamed mucosal lining.Recent advances in endoscopic technology and a better understanding of the importance of the ostiomeatal complex in the pathophysiology of sinusitis have led to the establishment of functional endoscopic sinus surgery (FESS) as the surgical procedure of choice for the treatment of chronic sinusitis.[33]FESS facilitates the removal of disease in key areas, restores adequate aeration and drainage of the sinuses by establishing patency of the ostiomeatal complex, debulks severe polyposis, and causes less damage to normal nasal functioning. FESS is successful in restoring sinus health, with complete or at least moderate relief of symptoms in 80-90% of patients. Supportive medical treatment is instituted preoperatively and postoperatively. In children, surgical management is not as well established and should be reserved for complicated cases.Occupational exposure may affect FESS outcomes. Symptoms may persist with work-related exposure to inhaled agents, and revision surgery may be required.[34]For more information, see the Medscape Reference articleFunctional Endoscopic Sinus Surgery.Management of Chronic Maxillary SinusitisThree main surgical options are available for chronicmaxillary sinusitis: Endoscopic uncinectomy with or without maxillary antrostomy Caldwell-Luc procedure Inferior antrostomy (naso-antral window)Management of Fungal SinusitisThe preferred treatment for chronicfungal sinusitisis surgical debridement.Mycetomasor fungus balls are best treated by means of surgical removal. Allergic fungal sinusitis, which usually manifests as nasal polyps and allergic sinusitis, is treated by means of systemic steroids and surgical removal of polyps and mucinous secretions. Prolonged postoperative tapering doses of prednisone and anterior nasal glucocorticoid steroids are indicated to suppress the symptoms of fungal CRS.Some literature has suggested that topical antifungals may have a role in the treatment of CRS[35]; however, this treatment remains controversial, and other studies have not supported this approach. A recent assessment that included 6 studies (N = 380) showed no statistically significant benefit of topical or systemic antifungals over placebo for the treatment of CRS.[36]Dietary MeasuresGarlic has an active ingredient (allyl thiosulfinate) that provides a short-term decongestant effect. Eating foods highly seasoned with garlic has been considered therapeutic. Chewing horseradish root is another home remedy reported by some patients as effective for clearing the sinuses, but no scientific data support this belief.ComplicationsThe most common complication of chronic sinusitis is superimposed acute sinusitis. In children, the presence of pus in the nasopharynx may cause adenoiditis, and a high percentage of such patients develop secondary serous or purulent otitis media. Dacryocystitis and laryngitis may also occur as complications of chronic sinusitis in children.Patients should be urgently referred to an otolaryngologist when they manifest any of these signs and/or symptoms: double or reduced vision, proptosis, rapidly developing periorbital edema, ophthalmoplegia, focal neurologic signs, high fever, severe headache, meningeal irritation, or significant or recurrent nose bleeding.[18]Orbital complications include preseptal cellulitis, subperiosteal abscess, orbital cellulitis, orbital abscess, and cavernous sinus thrombosis. Intracranial complications include meningitis, epidural abscess, subdural abscess, and brain abscess.[18]Other complications include osteomyelitis and mucocele formation.Some studies have suggested a higher incidence of complications associated with fungal sinusitis.[37, 38]Untreated chronic sinusitis can lead to life-threatening complications, as in patients with cystic fibrosis.[39]ConsultationsPersistent or recurrent episodes of sinusitis despite appropriate medical therapy necessitate referral to an otolaryngologist. Examination, including nasal endoscopy and CT scanning, is mandatory to exclude surgically amenable conditions.A consult with an otolaryngologist should be considered when one of the following occurs: The disease is refractory to maximal medical therapy. The disease has progressed beyond the paranasal sinuses. The disease is unilateral (patient should be evaluated for potential neoplasm). Patients have coexisting morbidities that are exacerbated by the sinus disease. Urgent referral when a complication is suspected (see above)Seek consultation with an ophthalmologist at the earliest suggestion of orbital involvement. Seek consultation with a dentist when an odontogenic infection is present or suspected.Long-term MonitoringContinued outpatient medical treatment with nasal decongestants and topical steroids is important even after surgical treatment.Nasal douching may improve symptoms, particularly following surgical treatment. Steam inhalation may have a role to liquefy and soften crusts while moisturizing dry inflamed mucosa.Nasal cavity irrigation using buffered normal saline may have a role in decreasing mucosal edema. Irrigation should be performed at least twice daily.Patients with presumed allergic rhinitis in conjunction with chronic sinusitis may benefit from an evaluation by an otolaryngologist trained in otolaryngic allergy or an allergist/immunologist. In most instances, prick/puncture tests are performed to clarify the role of allergies.