11.current management of rhinosinusitis-kiagus yangtjik
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BIODATA
NAMA : Dr. Kiagus Yangtjik , SpAK
ALAMAT : Jln.Sersan Sani No. 3440 Kel. Sukabangun
Palembang
TEMPAT/ TGL.LAHIR : Palembang, 18 Mei 1951
AGAMA : Islam
PEKERJAAN : PNS
EMAIL : [email protected]
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Management Rhinosinusitis in children
KIAGUS YANGTJIK
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Sinusits & Rinosinusitis
1. Embriologis mukosa sinus lanjutan dari mukosa hidung
2. Sinusitis hampir selalu didahului oleh rinitis
3. Gejala Obstruksi nasi, rinore dan hiposmia dijumpai pada rinitis dan sinusitis
• Rhino-sinusitis is an inflammation of the mucous membrane of nose and paranasal sinuses
American Academy of Otolaryngology-Head and Neck Surg,1996
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Kids = Adults
• Children are susceptible to 6-8 episodes of nasopharyngitis (viral) per year (adults endure 1-4 episodes)
– 2-5% of these episodes may be accompanied with bacterial infections
• Rhinosinusitis in pediatric population is different than in adults
Wald ER, Guerra R, Byers C. Pediatrics. 1991; 87 129-133
Aitken M, Taylor JA, Arch Pediatr Adolesc Med 1998;152:244-258
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Anatomy
• Maxillary Sinus – first to develop at day 65 of gestation – seen on plain films at 4-5 months – slow expansion until 18 years
• Ethmoid Sinus – develop in third month of gestation – ethmoids seen on radiographs at one year – enlarges to reach adult size at age 12
• Sphenoid Sinus – originates in fourth gestational month from posterior part of nasal cavity – pneumatization begins at age 3 – rapid growth to reach sella by age 7 and adult size at age 18
• Frontal Sinus – begins in fourth month of gestation from superior ethmoid cells – seen on radiographs at age 5-6 – grows slowly to adult size by adolescence
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Rhinosinusitis
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ISPA pada anak 6-8 kali / tahun
5- 10%
Rinosinusitis
Rinosinusitis bacterial Akut
2 – 10%
Viral rinosinusitis
90-98%
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Clasification
• Acute: symptoms often inseparable from URI and include rhinorrhea, daytime cough, nasal congestion, infrequent low-grade fever, otitis media, irritability and headache. Key in diagnosis of sinusitis is persistence beyond 7-10 days or worsening of symptoms at around 7 days – Severe Acute Sinusitis: purulent rhinorrhea, high fever, periorbital edema
• Recurrent: complete resolution between episodes and 3 or more episodes in six months or more than 4 episodes in one year
• Subacute: signs and symptoms lasting three weeks to three months • Chronic: signs and symptoms lasting longer than three months
AAP. 2001
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Rhinosinusitis per Symptoms/Signs (requires 2 Major Factors, or 1 Major & 2 Minor)
–Facial Pain / Pressure –Nasal Obstruction / Nasal Congestion –Nasal or Post-Nasal Discharge /Purulence –Hyposmia / Anosmia –Cough not due to Asthma
• (in children only)
Minorinor Factors
–Headache
–Fever
–Halitosis
–Fatigue
–Dental Pain
–Cough (in adults)
–Otologic symptoms
Mayor Factors
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Why pain ?? Air trapped within a blocked sinus, along with pus or other secretions may cause pressure on the sinus wall that can cause the intense pain of a sinus attack.
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Etiologi Bacterial
• Acute : Sterptococcus pneumoniae 33%
Haemophilus influenzae 25%
Moraxella cataralis 20%
Streptococcus pyogenes (betahemolitic) 5%
• Cronis Sterptococcus pneumoniae
Haemophilus influenzae
Moraxella cataralis
Streptococcus pyogenes (betahemolitic)
Anaerob bacterial (peptostreptococcus,fusobacterium)
Pseudomonas
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Acute RS : Bacterial versus Viral
Signs / Symptoms more likely Bacterial than Viral:
• Symptoms worsening after 5-6 days, or persisting more than 10 days, or out of proportion to those typically associated with viral URI
• Unilateral Midfacial, Periorbital or Forehead Pain
• Pain worsened by bending over or Valsalva, “Toothache”
• Unilateral purulent Rhinorrhea
• Poor response to Decongestants
• Facial Swelling, Conjunctival Injection, Meningeal or other Signs of spread outside of the sinus(es)
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7–10 Days 3 Months
Viral
Aerobes Resistant Aerobes, Anaerobes & Fungi
Causes of Rhinosinusitis – Time Course
0
20
40
60
80
100
Time
Perc
en
t o
f P
ati
en
ts
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Duration of Symptoms in Viral URIs
1 2 3 4 5 6 7 8 9 10 11 12 13 14 0
10
20
30
40
50
60
70
Day of Illness
Fever
Sore Throat
Cough
Nasal Drainage
Perc
ent
of
Pati
ents
Wit
h S
ymp
tom
s
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Pathogenesis
• Ostia obstruction creates increasingly hypoxic environment within sinus
• Retention of secretion results in inflammation and bacterial infection
• Secretion stagnate, obstruction increases, cilia and epithelial damage become more pronounced
• Most common inciting event is viral URI
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Shortcut to acute sinusitis micro.lnk
Sinus and Allergy Health Partnership Otolaryngol Head Neck
Surg 2004:130:1 17
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Sinus & Allergy Partnership. Otolaryngol Head & N Surg 2004; 130:1 18
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Acute Bacterial Rhino sinusitis - Treatment
Antibiotics x 2 weeks
Amoxycillin clavulanat (90mg/KgBB)
(10 – 14 h) ?
• Macrolides (30% resisten thd S Pneumonia)
• TMX –SMT (30-40% ) resisten S. Pneumonie & H.Influenza)
• Doxycyclinne no recomend to child
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© The Author 2012. Published by Oxford University Press on behalf of the
Infectious Diseases Society of America. All rights reserved. For Permissions,
please e-mail: [email protected].
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PERBAIKAN 3-5 HR PERBAIKAN 3-5 HR
PERBURUKAN 3 – 5 HR
LANJUTKAN 5-7 HR
GANTI ANTIBIOTIKALANJUTKAN 5 -7 HR
PERBURUKAN 3 – 5 HR
• CT/ MRI
• CULTUR SINUS/MEATUS
PERBAIKAN PERBAIKAN
RESIKO RESISTEN
RESIKO RESISTEN
1. UMUR < 2 TH
2. SDH MENDAPAT AB
SEBELUMNYA
3. SDH DIRAWAT
SEBELUMNYA
4. ADA COMORBIDITAS
5. IMMUNOCOMPROMISE
REFER SPESIALIS
LANJUTKAN 5-7 HR
LANJUTKAN 5-7 HR
ALGORITMA TATALAKSANA ACUTE BACTERIAL RINOSINUSITIS
GEJALA
1. MENETAP (>10HR)
2. BERTAMBAH BERAT (>3 – 4HR)
3. PERBURUKAN/PENY.LAIN (. 3-4 HR)
ANTIBIOTIKA 2SC
YATIDAK
ANTIBIOTIKA 1ST
PENGOBATAN
SIMTOMATIK
Chow A W et al. Clin Infect Dis. 2012;cid.cir1043
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List of Antibiotics
1st Line
• Amoxicillin
• TMP-SMX
• Erythromycin
2nd Line
• Clarithromycin
• Azithromycin
• Augmentin
• Cephalosporins
• Levofloxaxin
• Clindamycin
• metronidazole
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Chronic Rhinosinusitis
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Chronic Rhino sinusitis - Symptoms
Usually less - no pain
Symptoms for > 12 weeks
Nasal obstruction
Nasal/Post nasal purulnt discharge
Cacosmia
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Chronic Rhino sinusitis - Signs
Mucopus in the meati
Nasal mucosa congested
X-ray show fluid level or opacity
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Diagnosis of CRS
• Physical examination – Endoscopy or anterior rhinoscopy
• Purulent drainage
• Edema or erythema of the middle meatus or ethmoid bulla
• polyps
• Sinus CT scan – Mucosal thickening
– Air-fluid level
Meltzer et al. JACI 2004;114:155 25
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Microbiology of Chronic Rhinosinusitis
• Not well defined because of differences in culturing techniques, prior use of abx
• S. pneumoniae, H. influenzae, M. catarrhalis
• S. Aureus, coagulase negative staph, anaerobes
• Fungi
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Medical Management of Chronic Rhinosinusitis
• Antibiotics
• Corticosteroids
• Decongestants
• Muco-evacuants
• Antihistamines
• Non-pharmacologic treatment
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Chronic Rhino sinusitis - Treatment
• Surgical
– Open-depends on the site
• Caldwell-Luc Operation
• Osteoplastic flap
– Endoscopic-FESS
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Surgery for Rhinosinusitis
• FESS
– enlarge sinus ostia
– correct anatomic deformities (septal deviation, concha bullosa)
– create a common cavity for nasal drainage
– ventilate sinuses
– >85% improvement in selected series
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FESS
• Functional Endoscopic Sinus Surgery
• ? Funtional
– resume the normal function of sinus
• drainage
• ventilation
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FESS-complication
• Local – Bleeding – Adhesion – Mucocele – Stenosis – Recurrence
• Orbital – Orbital haematoma – Diplopia – Blinding
• Intracranial – CSF leakage – Meningitis
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Complications of Rhino sinusitis
• Local – Mucocele
– Osteomyelitis-Pott’s tumor
• Orbital – Orbital cellulitis
– Orbital abscess
– Cavernous sinus thrombosis
• Intracranial – Epidural abscess
– Subdural abscess
– Intracerebral abscess
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Chronic Rhinosinusitis: Which Antibiotic to Use?
-No antibiotic is approved by FDA for CRS
-We use similar abx as ABRS
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Antibiotics for Chronic Rhinosinusitis
• Appropriate duration is not well defined
• AAAAI and ACAAI Joint Task Force
– treat for 3,4 or 6 weeks
– continue abx for at least 1 week after the patient is symptom free
• Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery
– treat 4 to 6 weeks
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Adjunctive Therapy
• Dekongestan dan antihistamin :
Tidak ada obat Dekongestan baik oral maupun lokal dan
Antihistamin direkomendasikan untuk rinosinusitis akut bakterial (low moderate)
• Kortikosteroid :
Dapat diberikan rinosinusitis dengan riwayat atopi (low
moderate )
• Irigasi :
Hanya untuk dewasa pd ABRS (weak low moderate )
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Nasal Irrigation
• Improves mucociliary function
• Decreases mucosal edema
• Decreasing inflammatory mediators
• Clearing mucus
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Prognosa rinosinusitis
• Dengan tatalaksana yang baik dan optimal tindakan operasi jarang dilakukan pada anak
• Kekambuhan sangat tergantung dari Etiologi dan faktor predisposisi
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Summary
• Acute rhinosinusitis is usually related to infection – Antibiotic management is first line
• Chronic rhinosinusitis is usually related to inflammation – Further characterization of the condition is important
(nasal polyps)
– Exploration of underlying allergy is important
– Management is challenging
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Thank you
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