CASE REPORT

CHRONIC RHINOSINUSITIS

Presenter:
Muhammad Hanif bin Zaini
Ayunda Dewi Jayanti J. P.
Rahmadhani Drajati Imana Putri
Anindita Putri
Aflyana Anggreni R
Yunardi Singgo

Moderator:
dr. Hafifah

2015
INTRODUCTION
Chronic rhinosinusitis (CRS) is a
heterogeneous group of inflammatory
diseases of the nasal and paranasal
cavities either accompanied by polyp
formation (CRSwNP) or without polyps
(CRSsNP)1. Both types of CRS are
prevalent medical conditions associated
with substantial impaired quality of life,
reduced workplace productivity, and
serious medical treatment costs1-2.
Chronic rhinosinusitis’ true
prevalence still unknown, but believed
high. According to the National Health
Interview Survey of 1996, chronic sinusitis
was the second most prevalent chronic
health condition, affecting 12.5% of the
US population or approximately 31 million
patients each year1-2. Rhinosinusitis
prevalence in Indonesia is considered high.
According to Dewanti (2008), there was
118 patient with chronic rhinosinusitis on
2006-20073.
According to EPOS (2012),
rhinosinusitis in adults is defined as
Inflammation of the nose and the
paranasal sinuses that indicated by 2 or
more symptoms, one of which should be
either nasal blockage or nasal discharge
(anterior/posterior nasal drip) ± facial
pain/pressure, ± reduction or loss of
smell; And either endoscopic signs of
Nasal polyps, and/or Mucopurulent
discharge primarily from middle meatus
and/or Edema/mucosal obstruction
primarily in middle meatus; And/or CT
changes of Mucosal changes within the
osteomeatal complex and/or sinuses4-5.
The nasal cavity warms and
humidifies inspired air and filters out
small airborne particles. The nasal cavity is
lined with the ciliated pseudostratificated
columnar with goblet cells that secretes a
mucinous substance aiding in mucociliary
clearance of small particles trapped on
the mucosal surface6.
The nasal cavity also provides
drainage for secretions from the
paranasal sinuses and traps odor-bearing
particles for olfaction to the olfactory
recesses. Paranasal sinuses assist
physiological functions as they humidified
inspired air, lightening the skull, regulating
intranasal pressure, enhancing olfaction
and adding resonance to the voice. The
anterior paranasal sinuses drain their
content by way of osteomeatal complex6.
Ostiomeatal complex are the area
on the lateral nasal wall (middle meatus)
that receives drainage from the anterior
and medial ethmoid cells, frontal sinus,
and maxillary sinus. It is an anatomically
constricted area that is prone to blockage,
especially in the presence of structural
anomalies, mucosal swelling or tumors. In
addition, ostia themselves are small. An
impairment in the ventilation of sinus due
to such reasons lead to Chronic
rhinosinusitis (CRS)6.
The etiology and pathogenesis of
chronic rhinosinusitis is much less clear,
and majority of cases are idiopathic1.
Frequently, Rhinosinusitis could be caused
by Allergen, infection such as
Staphylococcus aureus (30%) and
Pseudomonas aeruginosa (17%). Many
review study proposes some hypothesis
related to CRS pathophysiology. The main
problem in rhinosinusitis is defect in
drainage function and mechanical barrier
of sinus. Defects in the mechanical barrier
and/or the innate immune response of
the sinonasal epithelium will increase
microbial colonization and accentuated
barrier damage, making sinonasal mucosa
more susceptible to antigen exposure,
results in chronic inflammation7-8.
Three pathophysiologic factor
related to chronic rhinosinusitis are host
factor, microbial factor and environment
factor2. Host factor such as genetic factor,
structural factor, and defect in immune
system. Retention of secretion due to
mucociliary dysfunction can be found in
immotile cilia syndrome (Kartagener
syndrome) and cystic fibrosis. Edema of
nasal mucosa in allergic rhinitis at the site
of sinus ostia may compromise ventilation
and even obstruct sinus ostia, leading to
mucus retention and infection. Certain
anatomic variation such as concha bullosa,
nasal septal deviation and a displaced
uncinated process, have been suggested
as potential risk factor for developing CRS.
Smoking, both active and second hand, is
a strong risk factor for CRS as smoking
suppress mucocilliary clearance within
nose.7-8.
Due to possibility of high CRS
prevalence and high cost of treatment,
appropriate treatment for CRS is a must,
not only to lower burden of disease, but
also to prevent upcoming complication.
CASE REPORT
Male patients 27 y.o, came as an
outpatient to the department of ENT
RSUD Purworejo with chief complaint
nasal blockage. Patient is complaining
about having nasal congestion since 4
months ago, along with headache, facial
pain, and nasal congestion. Patient also
complained having a yellowish green
mucous with malodorous smell running
out from his nose. Patient also
complained that when he wakes up, he
felt like something dripping into his throat.
Patient didn’t get any medication yet.
Patient is an active smoker. Patient stated To diagnose rhinosinusitis there
having history of gastritis and toothache, are major and minor criteria according to
and he didn’t go for tooth treatment. Task force. On this patient, there were
History of hypertension and DM were major criteria such as nasal blockage, post
denied. There is no history of nasal drip, hyposmia, and facial pain.
hypertension and DM on his family. These objective finding supported
From general inspection, patient mucopurulent secrete on anterior
looked good vital signs are within normal rhinoscopy. Patient was diagnosed having
limits. From right nose physical chronic sinusitis because he had these
examination, there is no skin lesion, no symptoms for more than 12 weeks (4
inflamation, and no mass . From palpation months).
we found facial pain on sinus maxillaris Upper jaw teeth infection P1, P2,
and sinus frontalis bilateral, no also M1, M2, M3 (dentogen) could cause
supraorbital pain, and no crepitation. maxillary sinusitis9. Maxillary antrum has a
From anterior rhinoscopy we found close link to premolar and upper molar
mucopurulent discharge and mucosa roots. These links might give rise to clinical
hyperemic, conchae hyperemic, edema, problems such as infection of those teeth,
and discharge. Examination on left nose oroantral can rise up to the sinus and
within normal limit. From mouth causing sinusitis. Maxillary sinusitis begins
examination there was caries on upper when bacteria from caries dentin entering
right molar 1. Oropharynx, ear, and sinus, causing inflammation. Inflammation
throat examinations are within normal process will disturb sinus drainage9.
limit. The patient was diagnosed with There are many choices of
chronic rhinosinusitis. He was treated treatment for Chronic rhinosinusitis, such
with clindamycin 2x300mg, Tremenza as nasal saline irrigation, intranasal
(Tripolidin HCl 2.5 mg dan steroid, systemic antibiotic, systemic
pseudoephedrine HCl 60 mg) 2x1, and glucocorticoids, topical steroid irrigation
Ambroxol 30mg 3x1. After symptom’s and topical antibiotic10-11.
relieved, patient would be referred to Nasal saline irrigation is effective
dentist to get tooth treatment. as adjunctive treatment, but less effective
as monotherapy than topical
DISCUSSION glucocorticoid. Isotonic or hypertonic
saline solution delivered by bottle, spray,
pump or nebulizer are frequently used in
treatment of sinus disease, mainly as
supplement. Irrigation reduces postnasal
drainage, removes secretions, rinses away
allergens and irritants and improves
mucociliary clearance4-5. Sodium
hypochlorite (NaOCl) is a well-known
bleaching and disinfecting agent that has
been found to be effective against S.
aureus and P. aeruginosa. Nasal irrigation
with 0.05% NaOCl was significantly more
effective than saline alone (Level of
evidence IIb). Xylitol could also be used
for nasal irrigation. Xylitol irrigation
results in greater improvement of
symptom of CRS, compared to saline
irrigation (Ib)4-5.
Intranasal steroids such as
budesonide, ciclesonide, fluticasone
furoate, fluticasone propriate,
mometasone furoate, and triamcinolone
acetonide, are helpful in all types of CRS
and are the cornerstone of maintenance
treatment4-5. The clinical efficacy of
steroid may depend in part of their ability
to reduce airway eosinophil infiltration by
preventing their increased viability and
activation. Many randomized controlled
trials have evaluated the efficacy of
topical corticosteroids and stated topical
intranasal steroid is effective for chronic
rhinosinusitis, both for CRS with polyps
and without polyps (level of Evidence Ia).
However, a certain meta-analysis showed
no difference between corticosteroid
group and placebo group4-5. However, a
different corticosteroid compound and
different method of delivery should be
considered as a factor affecting successful
of the therapy. Systemic corticosteroid
has been studied primarily as a treatment
for nasal polyp. Its efficacy for CRS
without polyps is still unclear and not
recommended for use (level of evidence
IV) 10-11.
Systemic antibiotic should be given
for CRS patients with persistent purulent
drainage and documented infection with S.
aureus or P. aeruginosa. Short-term
treatment might be relevant for
exacerbation with a positive culture (Ib)4-5.
Long-term systemic macrolide antibiotic
treatment has been proposed as a
treatment for CRS without nasal polyps
(level of evidence Ib). EPOS (2012)
recommended that long-term antibiotic
treatment should be reserved for patients
where nasal corticosteroid and saline
irrigation has failed to reduce symptom to
acceptable level. Moreover, there is some
indication that CRS patients with normal
IgE do better than patients with increased
IgE10-12.
 For treatment of chronic patient is dubia. Patient was educated to
rhinosinusitis, we follow guideline take medicine properly and come back to
established by PERHATI-KL. The treatment doctor 1 week later for control. Patient
depends of existing predisposing factor. was suggested to visit dentist after the
On this patient, the predisposing factor is symptom’s better.
caries dentis, so the patient should
receive antibiotic and supportive Further Readings
medication to relieve symptom. Antibiotic 1. Bachert, C., Pawankar, R., Zhang, L.,
given to patients was clindamycin, a Bunnag, C., Fokkens, WJ, et al. ICON:
macrolide-type antibiotic that acts by Chronic rhinosinusitis. World Allergy
inhibits bacterial growth. Nasal Organization. 2014. 7(25): pp. 1-28.
decongestant and mucolytic were given 2. Patel. JM, Hwang PH. Nonpolypoid
for supportive treatment. After the Rhinosinusitis: Classification,
symptom relieved, patient would be Diagnosis, and Treatment. In Bailey BJ

referred to dentist to get tooth & Johnson JT, Head & Neck Surgery-

treatment`13. Otolaryngology. 5th edition. Lippincott

Williams & Wilkins. 2014. Pp: 535-
The problem of this case is
549.
recurrence. The presence of caries dentin
3. Selvianti & Irwan Kristyono.
would make bacteria within teeth invade
Patofisiologi, Diagnosis dan
sinus maxilla again. Therefore, tooth
Penatalaksanaan Rinosinusitis Kronik
treatment is a must to prevent the
Tanpa Polip Nasi Pada Orang Dewasa.
recurrence of rhinosinusitis.
Universitas Airlangga. Surabaya. 2011.
4. Fokkens, WJ., Lund, VJ., Mullol, J.,
CONCLUSION
Bachert, C., Alobid, I., et al. EPOS
Male patients, 27 y.o, with chief
2012: European Position Paper on
complain nasal blockage. From history
Rhinosinusitis and Nasal Polyps 2012,
taking and physical examination were
Summary for Otolaryngologist. Rhinol
diagnosed as chronic rhinosinositis.
Suppl. 2012. Mar(23): pp.1-12.
Patient was given clindamycin 2 x 300 mg,
5. Fokkens, WJ., Lund, VJ., Mullol, J.,
Tremenza (Tripolidin HCl 2.5 mg &
Bachert, C., Alobid, I., et al. EPOS
pseudoephedrine HCl 60 mg), and
2012: European Position Paper on
ambroxol 30mg 3x1. Prognosis of this
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