RHINOSINUSITIS

Supervisor :
dr. Oscar Djauhari, Sp.THT-KL
Presentator :
Belinda Anabel (2015.061.002)

CASE DISCUSSION
25yo, has been having toothache for 2

years, secret on left nostril. Its greenish,

grimy, stinky.

CASE DISCUSSION
A. PATIENTS IDENTITY
Name

:T
Gender : Female
Age
: 20 years old
Occupation : Employee
Address : Cikole

CASE DISCUSSION
Chief Complaint : yellowish stinky-odor discharge from her left nose
Additional Complaint : Fullness and difficulty in breathing and smelling of the left nose
History of Present Illness
The patient came to the hospital with complaints of yellowish stinky odor discharge

from her left nose. The discharge is not massive, but it smells bad. She felt this since
3 weeks before admission, she also feels that the discharge is flowing down from her
nose to her throat without intending to.
She had a fever about 2 weeks before admission, followed with dull pain on her right
face and head and radiates to the teeth. There was also profuse nasal discharge at
that time. Currently, the patient also complains of fullness and difficulty in breathing
and smelling from her left nose. She has been feeling this since 2 weeks before
admission.
The patient admits she had been having a toothache on her left molar tooth since 2
years ago. She denies the presence of allergy, sneezing, itching of the nose, recent
common cold or cough, trauma on the nose, and infection of the upper respiratory
tract. She also denies 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 medication.

CASE DISCUSSION
History of Past Illness

Toothahce since 3 years before admission.

History of Family Illness

History of family illness was denied

CASE DISCUSSION
C. PHYSICAL EXAMINATION
General condition : Moderately ill
Body weight

: 50 kg
Height
: 155 cm
Blood pressure : 110/70 mmHg
Pulse
: 80 beat per minute
Respiratory rate : 24 times per minute
Temperature
: 36,3oC

CASE DISCUSSION
ENT Examination
Ear
Right ear

Auricle : with in normal range

External auditory canal : hyperemic (-), edema (-), mass (-),
laceration (-) secretion (-) , cerumen (-)
Tymphanic membrane : Intact, bulging (-), retraction (-),
light reflex (+)
Left ear
Auricle : with in normal range
External auditory canal : hyperemic (-), edema (-), mass (-),
laceration (-) secretion (-) , cerumen (-)
Tymphanic membrane: Intact, bulging (-), retraction (-), light
reflex (+)

CASE DISCUSSION
Nose

Right nose
Mucous membrane: hyperemic(-), edema(-), secretion(-), crust(-),
mass(-).
Conchae : hypertrophic(-), hyperemic(-), meatus secrete(-)
Septum : no deviation
Air passage: normal
Left nose

Mucous membrane: hyperemic(-), edema(-), secretion(-), crust(-),

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

CASE DISCUSSION
Oropharynx

Posterior pharynx : hyperemic (-)

Palatine tonsils : T1 / T1, hyperemic (-), detritus (-)
Uvula : symmetrical
Dental : no abnormatlities
Nasopharyngeal laryngoscopy : Post nasal drip

mucopurulence (+),mass (-), meatus tuba eustachius (+/+),

corpus alienum(-)
Maxillofacial

: symmetrical, tenderness on the left

zygomatic bone
Neck

: mass (-), lymphadenopathy (-)

WORKING DIAGNOSIS
Acute rhinosinusitis maxillaris unilateral et

causa odontogenic.

WORK-UP
Transillumination test
Radiologic examination : plain film x-ray of

Waters position, Skull AP position or

coronal section CT-scan
Nasoendoscopy

TREATMENT
Outpatient care
Refer to dentist for tooth extraction
Antibiotic : Co-amoxiclav 3 x 625 mg PO for

7 days
Decongestant : Pseudoephedrine HCl
120mg 2x1 tab

DEFINITION
Rhinosinusitis comprises a spectrum of

medical conditions that are characterized

by inflammation in the nose and paranasal
sinuses.
These are divided into acute, subacute, and
chronic rhinosinusitis, depending on
duration.
Acute sinusitis typically lasts 4 weeks or
less.
Subacute sinusitis lasting 4 to 12 weeks.
Chronic sinusitis characterized by
inflammation syptoms lasting 12 weeks or

ANATOMY
PARANASAL SINUSES
- air space within certain bones of the skull
- decrease skull bone weight, sound resonance
- consist of : frontal, ethmoidal, sphenoidal, maxillary

ANATOMY
Maxillary Sinuses
the largest
behind the cheekbone, extending from just

beneath the eyes to above the upper teeth

on either side of the nose
so close with the root of jaw of the upper
teeth so the infection usually spread up

ANATOMY
Frontal Sinuses
above

the nose, in the forehead and

between eyes
begin to grow around age 5, and full
development is during teenage years
drain into middle nasal meatus

ANATOMY
Ethmoidal Sinuses
behind the eyes and behind the bridge of

the nose
consists of seven to fifteen chambers
the anterior, drains into middle nasal
meatus
the posterior, drains into superior nasal
meatus

ANATOMY
Sphenoidal Sinuses
behind the nose, behind the eyes and at

the base of the brain

derived from ethmoidal sinuses
drain along the posterior wall of the nasal
cavity into the pharynx

ETIOLOGY

Aerobic Bacteria

Anaerobic bacteria

Streptoccocus Pneumonia

Peptostreptococcus

Haemophilus Influenzae

Bacteroides spp.

Streptococcus Group A

Fusobacteria

Moraxella Catarrhalis
Pseudomonas sp.
Klebsiella sp.

PATHOPHYSIOLOGY
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.

PATHOPHYSIOLOGY
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.

PATHOPHYSIOLOGY
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 will 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.

PREDISPOSITION FACTOR
Genetic/ physiological factor

-Airway hyperreactivity
-Immunodeficiency
-Aspirin sensitivity
-Ciliary dysfunction
-Cystic fibrosis
-Autoimmune disease
-Granulomatous disorders

PREDISPOSITION FACTOR
Environmental factor:

-Allergy
-Smoking
-Irritants, pollutions
-Virus
-Bactery
-Fungi
-Stress

PREDISPOSITION FACTOR
Structural factor

-septum deviation
-concha bullosa
-bone inflammation
-foreign body
-tooth disease

-haller cells
-frontal cells
-anomali craniofacial
-mechanical trauma
-barotrauma
-paradoxic middle

turbinates

CLINICAL MANIFESTATION
Complaint of post nasal drip, nasal discharge

(usually purulent, stinky, and sticky)

Dull pain of the face or cheek affected,
headache
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.

DIAGNOSTIC CRITERIA
Major

Minor

Facial pain/pressure
Nasal obstruction
Nasal discharge/discolored

postnasal drip

Headache
Fever (all nonacute)
Halitosis
Dental pain

Hyposmia/anosmia

Fatigue

Purulence in examination

Cough

Fever (acute only)

Ear pain/pressure/fullness

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 :

DIAGNOSIS
The infundibular pattern (obstruction in the

maxillary infundibulum, resulting in isolated maxillar

sinusitis)
Osteomeatal unit pattern (middle meatus
obstruction leading to ipsilateral sinusitisaffecting
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
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.

COMPLICATION
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
result in swelling of the cheek, and
sphenoid sinus mucocele may result in
oculomotor palsy.

THERAPY
Dentogene Sinusitis should be treat by

removed the infection tooth that cause

sinusitis. Antibiotic is also needed, especially
for anaerob bacteria:
Amoxicillin/ clavulanate
Alternative : Metronidazole + Levofloxacin
Irrigation of the nasal cavity with ceftazidime.
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.

THANK YOU