CASE PRESENTATION

Chronic Sinusitis

Supervisor :
dr. H. Oscar Djauhari, Sp. THT-KL

Presented by:
Annisa Tri Handayani

2011730010

Clinical Rotation
Ear Nose Throat Head and Neck Surgery Department
Medical Faculty of Muhammadiyah Jakarta
Syamsudin, S.H. Regional General Hospital, Sukabumi
9 May 2016 - 12 June 2016

Identity
Name
Age
Occupation

: Ms. A
: 27 years old
: employee

Weight
Address

: 52 kg
: KP. Cipanas RT006/009, Cisarua

Chief complaint
:
Additional complaint :

Stinky sticky yellowish discharge from the nose

Fullness and difficulty in breathing from the right nose

History of present illness

The patient came to the hospital with complaints of sticky yellowish discharge from
her right nose. The discharge is not massive, but it smells bad. She felt this since 3
months ago, she also feels theres some discharge flowing down on her back throat.
The history of fever was positive 1 month ago followed with dull pain on her face and
right head and radiates to the teeth, which is getting better after she ate panadol forte.
There was also profuse nasal discharge at that time. Currently the patient also
complaint of fullness and difficulty in breathing from her right nose, she feels like
there is something obstructing her right nose, making her voice slightly changed.She
has been feeling this for a long time (about 5 months ago),.
The patient denied the presence of allergy, sneezing, itching of the nose, decrease in
smelling ability (hyposmia), recent common cold or cough, trauma on the nose, and
infection of the upper respiratory tract. She also deny the presence of previous blood
discharge or pain from her nose, history of currently tooth removal, tootache, and
inserting something into her nose. The presence of hearing dysfunction, fullness in the
ear or any discharge from the ear is denied.
Currently she is not taking any drugs medication, and there is no family history of
tumors, hearing problems, hypertensive disease, diabetes mellitus.

History of past illness

The patient denied the history of allergy, operation or any tooth removal procedure,
high blood pressure, diabetes mellitus, allergy and infection of the nose, ear and throat
before.
History of family illness
History of tumor (-), allergy (-)
History of hypertension (-), diabetes (-)

General Physical Examination

General appearance : The patient is calm
Blood pressure
: 110/70 mmHg
Respiration rate
: 24x/min

Consciousness : Compos mentis

Heartbeat
: 80x/min
Temperature : 36.0

Face and neck :

Head :
Symmetric, deformity(-)
Eyes :
Anaemic, icteric sclera (-)
Nose :
secrete-/-, deviated septum (-), corpus alienum(-)
Mouth :
Mucous membrane moist.
Neck :
Lymph node enlargement (-)
Thorax :
Heart :

Pulmonary :

Inspection :
Palpation :
Percussion :

Ictus cordis non visible

Ictus cordis felt at the left midclavicular ICS IV
Upper border : left midclavicular ICS II
Left border : left parasternal ICS IV
Right border : Right sternal ICS IV
Auscultation : Regular heart sound I and II, murmur(-), gallop(-)
Inspection : Left and right hemithorax move symmetrically
Palpation :

Tactile fremitus can be felt symmetric in bot hemithorax, liver-

lung border at right midclavicular ICS V

Percussion : Sonor on both hemithorax
Auscultation : Vesicular breathing +/+, wheezing -/-, rhonci -/Abdomen :
Inspection :
Palpation :
Percussion :
Auscultation :

Appear flat, sicatrics(-), discoloration(-), enlarged veins(-),

Soft on palpation, tenderness(-), enlarged liver(-), enlarged spleen(-)
Tympany on all abdominal region
bowel sound(+) normal.

Skin :
Warm extremity, capillary refill time <3 seconds
Ear, Nose, Throat and neck Physical Examination
AURICLE
Right Auricle :
External ear
: hyperemic(-), deformity(-), laceration (-), mass (-), pain (-)
External acoustic canal : hyperemic(-), edema(-), laceration(-), secretion(-), cerumen
(-), mass(-).
Tymphanic membrane

: intact, light reflex(+) normal

Left Auricle :
External ear
: hyperemic(-), deformity(-), laceration(-), mass(-), pain(-)
External acoustic canal :hyperemic(-), edema(-), mass(-), laceration(-), secretion(-),
cerumen(-), mass(-).

 Tympanic membrane
Right nose cavity :
External nose
laceration(-).
Mucous membrane

: intact, light reflect(+) normal

: deformation(-), edema(-), hyperemic(-), mass(-),
: hyperemic(-), edema(-), secretion(-), crust(-), mass(+)

filling the nasal cavity, white grapes coloured, slightly mobile.

Conchae : hypertrophic(-), hyperemic(-), meatus secrete(+)sticky non profuse
yellowish discharge above the inferior concha.
Septum
: no deviation
Air passage
: slightly obstructed
Left nose cavity :
External nose

laceration(-)
Mucous membrane
Conchae
Septum
Air passage

Throat

: deformation(-), edema(-), hyperemic(-), mass(-),

: hyperemic(-), edema(-), secretion(-), crust(-), mass(-).
: hypertrophic(-), hyperemic(-), meatus secrete(-)
: no deviation
: normal

: Uvula is located in the middle, moist mucous membrane, mass(-),

hyperemic(-), lesion(-).
Pharynx

: Normal pharyngeal arch,hyperemic(-), edema(-), granulation(-)

Nasopharyngeal laryngoscopy : Post nasal drip (+), mass (-), meatus tuba eustachius (+/+),
corpus alienum(-)
Tonsils

: T1 / T1, hyperemic (-), enlarged crypts(-), detritus(-).

Neck

: Lymphadenopathy cervical lymph node (-).

Working diagnosis
Chronic rhinosinusitis maxillaris unilateral et causa suspect of polyp on the right nose
Differential diagnosis
(-)
Suggestion
- Transillumination test
- Radiologic examination : plain film x-ray of Waters position, Skull AP position
orcoronal sectionCT-scan
- Nasoendoscopy
Therapy
- Suggestion of FESS (Functional Endoscopic Sinus Surgery)
- Nasal wash with Ceftazidime and saline solution

Chronic Sinusitis
Definition
Chronic sinusitis is the infection of the sinus mucosa, which is usually due to the obstruction
of the osteomeatal unit. The distinction of acute and chronic infection of the sinusitis is that
acute infection usually last up to 2 weeks, meanwhile the chronic infection may persist up to
12 weeks or more.

Anatomy
Paranasal sinuses are mucosa-lined structures continuous with the nasal cavity. The functions
are:
-

Acting as resonating chambers for the voice

Provide protection to the brain from trauma
Moisturize and humidify ambient air
Lightening the weight of the facial skeleton

The secretes formed in the sinuses are drained to their perspective meatus. There are three
meatus, the superior, media, and inferior meatus. The superior meatus drains secretes from
the posterior ethmoidal cells; the media meatus through the semilunaris hiatus drains secretes
from the frontal sinuses, anterior ethmoidal, and maxillary sinuses; and the inferior meatus
drains secretes from the nasolacrimal duct.
The osteomeatal complex is a small constricted region which is prone to obstruction,
especially in the presence of congenital anomaly(Concha bullosa, septal deviation, septal
spurs), infection, tumors(polyp), trauma(anatomic deviations, septal deviations), and
others(allergic rhinitis, foreign bodies)

Fig. 1.1 Lateral of nasal

cavity

Risk Factors
The anatomical abnormalities such as septal deviation, bulla ethmoidalis, concha bullosa,
prominent uncinate process, narrow frontal recess, and nasal polyps may block the sinuses
ostia.
The conditions which impairs the mucociliary transport such as allergic rhinitis, nasal
polyposis, cystic fibrosis, primary ciliary dyskinesia, and Kartageners or Youngs syndrome.
Failure of the mucociliary clearance from the sinuses through the ostia may lead to the stasis
and the formation of pus in the sinus.
Cigarrette smoking may also affect the mucociliary clearance dysfunction which in turns
result in the retention of the secretes in the sinuses.

Pathophysiology
Most of the chronic sinusitis infection is usually bacterial, which develop secondary to the
primary viral sinusitis. While the acute sinusitis infection is mostly due to the Streptococcal
and other aerobic bacteria, chronic sinusitis mainly due to the accumulation of anaerobic
bacteria.

Aerobic Bacteria
Streptoccocus Pneumonia
Haemophilus Influenzae

Anaerobic bacteria
60%
cases

Streptococcus Group A
Moraxella Catarrhalis
Pseudomonas sp.

Peptostreptococcus
Bacteroides spp.
Fusobacteria
Mostly dentogen
etoiology

Klebsiella sp.
The origin of the maxillary sinusitis may be either dentogen or rhinogen. The location of the
alveolar bone of the tooth lies close to the base of the maxillary sinus, which therefore allows
a direct transmission of microorganism from the mouth to the sinus. Dentogen origin usually
results from the extraction of the tooth which accidentally tears the thin bone between the
sinus - alveolar bone and therefore making an open connection between the oral cavity and
the maxillary sinus, this is called the oro-antral fistula.
Rhinogen origin is mostly due to the impaired ventilation mechanism of the osteomeatal unit
secondary to stenosis or obstruction ( swelling of the nasal mucosa, mechanical obstruction).
The failure of the mucociliary clearance will result in secrete accumulation which ay block
the sinus openings.The blocked drainage of the sinus system (adjacent maxillary sinus/

anterior ethmoidal cells, frontal sinuses) cause the swelling of the narrow osteomeatal unit.
This establish a vicious cycle and may lead to recurrent acute inflammation and eventually
the persistent chronic sinusitis. Chronic sinusitis mostly affect the maxillary sinus and
ethmoidal cells, and less affect the frontal and sphenoid sinuses.

External components :
Air pollution impairing
clearance disturbance

A. Chonca bullosa (pneumatized middle turbinate)

mucociliary

B. Allergic rhinitis, congested hyperemic mucosa with pus

C. Dentogen chronic sinusitis
D. Nasal Polyp

Clinical Manifestation
Patient with chronic sinusitis may complaint of post nasal drip, nasal discharge (usually
purulent, stinky, and sticky), dull pain of the face or cheek affected, headache, some may
complain of obstructed nasal breathing. On acute exacerbation there might be facial
congestion, profuse nasal discharge, headache, dull pain in the face, and post nasal drip.
Polyp may be seen in physical examination of the nasal cavity based on the grading of the
polyp.

Hadleys clinical scoring of nasal polyp :

Grade I :

Small polyp, located within the middle meatus, and not exceeding the

Grade II :

inferior part of the middle concha.

Polyp within meatus and exceeding the iferior part of the middle

Grade III :

concha.
Polyp can be seen in the nasal cavity, exceeding the middle concha,

Grade IV :

however do not exceed the inferior part of the middle concha.

Polyp covers the entire nasal cavity.

Diagnosis
Diagnosis of chronic sinusitis can be made with the use of rhinoscopy and endoscopy of the
nasal cavity, observing the lateral wall of the nose (obstructed meatus, secrete in the meatus)
and the post nasal drip.
Plain film radiograph such as the waters position may show the opacification of the sinuses
involved, and the upright position to show the air-fluid level in the sinuses involved.
The best instrument to diagnose the chronic sinusitis is the use of CT scan, where we can
observe :
-

The infundibular pattern (obstruction in the maxillary infundibulum, resulting in

isolated maxillar sinusitis)

Osteomeatal unit pattern (middle meatus obstruction leading to ipsilateral sinusitis

affecting the frontal, maxillary sinuses, and the anterior of the ethmoid cells)
The sphenoethmoid recess (obstruction results in posterior ethmoid and sphenoid

sinusitis)
Sinonasal polyposis pattern (opacification of tissues)
Unclassified ( mucoceles, mucosal thickening without obstruction, retention cyst)

Complication
Incomplete treatment of the sinusitis may result in the complication due to the extension of
the infection to the adjacent structures:
A. Orbital Cellulitis
Mostly occurs in children where the ethmoid sinuss infected. Infection spreads from
the lamina papyracea into the orbit, passing through the bony dehicences or through
the throbosed communicating vessels. Initial manifestation may be cellulitis, then to

the pre septal infection which may end up with post septal infection. The formation of
abscess may impair vision.

B. Mucocele
This results from the obliteration of the sinus ostium and therefore cause the mucus
entrapment in the sinus. Frontal and ethmoid sinuses mucocele may cause
displacement of the globe infero-laterally, diplopia. Maxillary sinus mucocele may
Early orbital
cellulitis
Abscess
result in swelling
of the cheek,
and sphenoid sinus mucocele may
result in oculomotor

palsy.

formation

Maxillary

Sphenoid

Frontal

Treatment
The operative treatment of chronic sinusitis (also with the nasal polyp) might be the FESS
(Functional Endoscopic Sinus Surgery) which is less invasive and may be satisfactory.
The non-operative treatment of chronic sinusitis must be adequate to treat both aerobic and
anaerobic bacteria :
-

Amoxicillin/ clavulanate
Alternative : Metronidazole + Lefofloxacin
Irrigation of the nasal cavity with ceftazidime