12/04/2011 1 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 PERANAN AUGMENTIN PADA TERAPI RHINOSINUSITIS Cita Herawati RS Premier Bintaro
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12/04/2011
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Nama : Dr. Cita Herawati Murjantyo, Sp THT-KLTempat/tgl lahir : Yogyakarta, 15 MaretPekerjaan/jabatan :
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
91. Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline : Adult sinusitis. Otolaryngology Head & Neck Surgery; 2007; 137:S1-S31.
Term DefinitionAcute rhinosinusitis
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 thepatient 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
Viral rhinosinusitis(VRS)
Acute rhinosinusitis that is caused by, or is presumed to be caused by, viralinfection. 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 bacterial rhinosinusitis(ABRS)
Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterialinfection. 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, orb. symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial
improvement (double worsening)(Adapted from ref 1)
Classification by Duration of Symptoms ACUTE – lasting up to 4 weeks, with total resolution of
symptoms
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
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
β-Lactamase–producing bacteria were isolated in 46% of the patients
142. 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
Genetic/congenital cystic fibrosis, ciliary
dyskinesia
Local Anatomic obstruction Gastroesophageal reflux
Enviromental factors Microorganisms viral illness (children in
daycare) Pollutants cigarette smoke
Medications Rhinitis
medicamentosa
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Possible Strategies for Treating CRS
CRSCRS
Infectious
Allergy
TreatEtiology–– Allergen AvoidanceAllergen Avoidance– Antibiotics– Surgery
TreatEtiology–– Allergen AvoidanceAllergen Avoidance– Antibiotics– Surgery
IL-5, IL-4IL-8, IF-GM-CSF
IL-5, IL-4IL-8, IF-GM-CSF
AttenuateInflammation– Steroids– Immunotherapy– Antileukotrienes– Macrolides– Who knows what else?
AttenuateInflammation– Steroids– Immunotherapy– Antileukotrienes– Macrolides– Who knows what else?
Anatomic
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
Second-line For adults The respiratory quinolones ciprofloxin, levofloxacin, gatifloxacin, and moxifloxacin
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AugmentinTM - Reliable efficacy in ABRS
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, cefpodoximeproxetil, cefuroxime axetil or cefdinir
Several guidelines include amoxicillin- clavulanate as a first-line/second-line treatment option (France, Germany, USA, Spain, UK, Belgium, Netherlands, Finland, Canada) 8
217. Poole MD, Portugal LG. Treatment of rhinosinusitis in the outpatient setting. Am J Med 2005;118 (7A):45S–50S.8. Klossek JM, Federspil P. Update on treatment guidelines for acute bacterial sinusitis. Int J Clin Pract 2005; 59 (2): 230–238
Conclusion
CRS is multifactorial Treatment is based on patient’s