Rhinosinobronchitis,

isinvasiveprocedureneeded?
Nastiti Kaswandani Yayasan Penyantun Asma Anak Indonesia SUDDHAPRANA

Introduction
Mechanismsthatlinktheupper(nose,sinuses, larynx,pharynx,andtrachea)andlower (bronchiandlungs)airwaysegments Rhinitis sinusitis bronchitis(asthma) Unitedairwaydisease(UAD)

Sinusitis Rhinosinusitis Rhinosinobronchitis

ClassificationbyDurationofSymptoms
ACUTE lastingupto4weeks,withtotalresolutionofsymptoms SUBACUTE persistingmorethan4weeks,butlessthan12weeks,
withtotalresolutionofsymptoms

CHRONIC 12weeksormoreofsigns/symptoms RECURRENTACUTE 4ormoreepisodesperyear,withresolution

ofsymptomsbetweenattacks

DefinitionRhinosinusitis

Clement P, Arch Otolaryngol Head Neck Surg 1998;124:31-4

Etiology

Le J, Lipsky MS. Am J Managed Care 2004

Pathogenesis

Pathogenesis
Ostia obstruction hypoxic environment within sinus Retention of secretion inflammation and bacterial infection Secretion stagnate, obstruction increases, cilia and epithelial damage become more pronounced

PredisposingFactorsInChronic
rhinosinusitis (CRS)
HostFactors
Systemic
Allergicrhinitis Immunodeficiency
IgG subclasses IgA

Enviromental factors
Microorganisms viralillness(childrenin daycare) Pollutants cigarettesmoke Medications Rhinitis medicamentosa

Genetic/congenital cysticfibrosis,ciliary dyskinesia

Local
Anatomicobstruction Gastroesophageal reflux

Possiblemechanismsystemicinflammation upperandlowerairway

Rimmer J, Ruhno JW. MJA 2006;185:565-71

SignandSymptoms
Rhinore (serouspurulent) Nasalblockage Cough Facialpain Headache Fever(lowgrade hyperpyrexia) Periorbital edema Irritability

Major&Minorsignsandsymptoms indiagnosisofChronicRS
Majors: Facialpain/pressure Nasalcongestion/fullness N.obstruction/blockage N.discharge/purulence Hyposmia/anosmia Purulentrhinitis Fever(acutesinusitisonly) Minors: Headache Fever Halitosis Fatigue Dentalpain Cough Earpain/ pressure/fulln

ClinicalDiagnosisofrhinosinusitis
2ormoremajorfactors 1major&2minorfactors OrPurulenceonexamination Durationofsymptoms>10daysorworsen after57days

Kinney WC : otolaryngol Head Neck Surg 2002

Diagnosis
Anamnesisandphysicalexamination Radiology
Plain:notrecommendedin<6years CT:givemoreinformationanatomically

Microbiology:
Nasalsecret:normalflora Sinuslavage :goldstandardifcolony>104 U/mL (butinvasive)

Sinusitis

CT Scan

Isantibioticneededinacuterhinosinusitis ?

MedicalTreatment
AcuteSinusitis:
YoungchildrenwithmildtomoderateARS,amoxicillinat normalorhighdose Amoxilallergicpatients,treatwithacephalosporin severeallergy,treatwithmacrolide Nonresponders,moresevereinitialdisease,thoseathigh riskforresistantstrep,treatwithhighdose amoxil/clavulanate Parenteral ceftriaxone forchildrennottoleratingoral meds Durationoftherapyisusually1021daysoruntil symptomsresolveplus7days

MedicalTreatment
ChronicRhinosinusitis
4to6weekcourseofbetalactam stableantibiotic Adjuvanttherapywithnasalsteroidscommonly employed Antihistaminesespeciallyifunderlyingallergic conditionsuspected

MedicalTreatment

Sobol. Laryngoscope 2006;115:78-80

RefractoryRhinosinusitis
Considerassociatedconditions
Allergy Immunedeficiency Asthma Gastroesophageal refluxdisease CysticFibrosis PrimaryCiliary Dyskinesia (ImmotileCiliaSyndrome) AllergicFungalSinusitis

ModalitiesTreatment

Complications
Orbital:
Orbitalcomplicationsmorecommoninchildren thanadults Mostcommonismedialsubperiosteal abscess

Intracranial:
Morecommoninadolescents/adults Includemeningitis(mostcommon),epidural abscess,subdural abscess,intracerebral abscess, cavernoussinusthrombosis

SurgicalManagement
Antral Lavage needgeneralanesthesia Adenoidectomy benefitforhypertrophyadenoid,preschoolage FESS(functionalendoscopic sinussurgery)
Onlyaftermaximalmedicaltherapyhasfailedandpatient hasbeenscreenedandtreatedforanyunderlying conditions Concernfordevelopingnasalandsinusanatomyin childrenandpossibilityofalteringfacialgrowth

Surgicalmanagementinchildren
Roleofadenoidectomy: 1.reservoirforpathogenicbacteria 2.interferewithnasalmucociliary clearance 3.betterdrainage Overallsuccessofadenoidectomy50% Studiesshowreductioninthenumberof bacterialpathogensinthenasopharynx after adenoidectomy

Surgery
Childrenwhofailmedicaltherapybenefit fromsurgery Adenoidectomyrecommendedinitiallyfor children6yearsofage(noasthma,lowCT score) FESSandadenoidectomyforchildrenolder than6years(asthmaandhighCTscore)
Ramadan.Laryngoscope.2004

Chang P. Arch Otolaryngol Head Neck Surg 2004;130:1033-6

TheConsensusPanelforpediatricrhinosinusitis

AbsoluteindicationsforFESS: 1.completenasalobstructioninCForclosureof thenosebymedialization ofthelateralnasal wall 2.antrochoanal polyp 3.intracranialcomplications 4.mucocoeles ormucopyocoeles 5.orbitalabscess

AbsoluteindicationsforFESS(cont): 6.traumaticinjuryintheopticcanal 7.dacryocystorhinitis duetosinusitisand resistanttoappropriatemedicaltreatment, 8.fungalsinusitis 9.somemeningoencephaloceles 10.someneoplasms.

Possibleindications
childrenwithchronicrhinosinusitis thatpersists despiteoptimalmedicalmanagement(26weeksof adequateantibioticsandtreatmentofany concomitantdisease)andafterexclusionofany systemicdisease.

Childreneligibleforsinussurgeryrepresent onlyasmallfractionofchronicsinusitis

Conclusion
Rhinosinobronchitis isaunitedairwaydiseasethatis commoninchildren Diagnosisofrhinosinusitis mainlybasedonclinical findings Conditionsstronglyrelatedtochronicrhinosinusitis inchildrenareasthma,GER,dyskinesia cilia syndromeandimmunodeficiency Mostchildrendonotneedsurgeryunlesstheyare notrespondedtomedicaltreatment