case sinusitis-dr oscar

8/20/2019 Case Sinusitis-dr Oscar

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CASE PRESENTATION

Supervisor :

dr. Oscar Djauhari, Sp. THT

Presented by:Jessica Bratakencana !"#$!%"$!

Christi Er'ina !"#$!%"$!&(

Ed)in A*e+ander !"#$!%"$!&%

A*'in Jhan !"($!%"$!(-

O*i'ia Nathania H !"($!%"$!(

Clinical Rotation

Ear Nose Throat – Head and Neck Surgery Departent

!edical "aculty o# $nika %ta &aya &akarta

Syasudin' S(H( Regional )eneral Hospital' Sukabui

"ebruary *th +,-./!arch -0th +,-.

Identit/

Na0e 1 2r. A

A3e 1 ! /ears *d

Occupatin 1 student4ei3ht 1 %5 k3


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Address 1 RS n "5, Suka6u0i

Chie7 c0p*aint 1 Stink/ and /e**)ish dischar3e 7r0 the ri3ht nse

Additina* c0p*aint 1 se'ere headache

Histr/ 7 present i**ness

The patient ca0e t the hspita* )ith c0p*aints 7 stink/ /e**)ish dischar3e 7r0

his ri3ht nse since # 0nths a3. The dischar3e is nt 0assi'e, 6ut it s0e**s 6ad.

The histr/ 7 tthache )as psiti'e. He a*s c0p*ained a6ut se'ere headache.

Current*/ he is nt takin3 an/ dru3s 0edicatin, and there is n 7a0i*/ histr/ 7

tu0rs, hearin3 pr6*e0s, h/pertensi'e disease, dia6etes 0e**itus.

Histr/ 7 past i**nessThe patient denied the presence 7 a**er3/, snee8in3, itchin3 7 the nse, decrease in

s0e**in3 a6i*it/ 9h/ps0ia:, recent c00n c*d r cu3h, trau0a n the nse, and

in7ectin 7 the upper respiratr/ tract. He a*s den/ the presence 7 pre'ius 6*d

dischar3e r pain 7r0 her nse. The presence 7 hearin3 d/s7unctin, 7u**ness in the

ear r an/ dischar3e 7r0 the ear is denied.

Histr/ 7 7a0i*/ i**ness

Histr/ 7 tu0r 9$:, a**er3/ 9$:

Histr/ 7 h/pertensin 9$:, dia6etes 0e**itus 9$:

)eneral Physical E1aination

;enera* appearance 1 0derate*/ i**

Cnsciusness1 C0ps 0entis

B*d pressure1 "!e7t 6rder 1 *e7t parasterna* ICS I?

Ri3ht 6rder 1 Ri3ht sterna* ICS I?Auscu*tatin 1 Re3u*ar heart sund I and II, 0ur0ur9$:, 3a**p9$:


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Pu*0nar/ 1 Inspectin 1 >e7t and ri3ht he0ithra+ 0'e s/00etrica**/

Pa*patin 1 Tacti*e 7re0itus can 6e 7e*t s/00etric in 6t he0ithra+, *i'er$

*un3 6rder at ri3ht 0idc*a'icu*ar ICS ?

Percussin 1 Snr n 6th he0ithra+

Auscu*tatin 1 ?esicu*ar 6reathin3 E

Ri3ht Auric*e 1

E+terna* ear 1 h/pere0ic9$:, de7r0it/9$:, *aceratin 9$:, 0ass 9$:, pain 9$:

E+terna* acustic cana* 1 h/pere0ic9$:, ede0a9$:, *aceratin9$:, secretin9$:, ceru0en

9$:, 0ass9$:.

T/0phanic 0e06rane 1 intact, *i3ht re7*e+9: nr0a*

>e7t Auric*e 1

E+terna* ear 1 h/pere0ic9$:, de7r0it/9$:, *aceratin9$:, 0ass9$:, pain9$:

E+terna* acustic cana* 1 h/pere0ic9$:, ede0a9$:, 0ass9$:, *aceratin9$:, secretin9$:,

ceru0en9$:, 0ass9$:.

T/0panic 0e06rane 1 intact, *i3ht re7*ect9: nr0a*

Ri3ht nse ca'it/ 1

E+terna* nse 1 de7r0atin9$:, ede0a9$:, h/pere0ic9$:, 0ass9$:,

*aceratin9$:.

2ucus 0e06rane 1 h/pere0ic9$:, ede0a9$:, secretin9$:, crust9$:, 0ass9$:

Cnchae 1 h/pertrphic9$:, h/pere0ic9$:, eatus secrete234 sticky

yello5ish discharge above the in#erior concha.

Septu0 1 n de'iatin

Air passa3e 1 slightly obstruction

>e7t nse ca'it/ 1

E+terna* nse 1 de7r0atin9$:, ede0a9$:, h/pere0ic9$:, 0ass9$:, *aceratin9$:

2ucus 0e06rane 1 h/pere0ic9$:, ede0a9$:, secretin9$:, crust9$:, 0ass9$:. Cnchae 1 h/pertrphic9$:, h/pere0ic9$:, 0eatus secrete9$:


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Septu0 1 n de'iatin

Air passa3e 1 nr0a*

Thrat 1 @'u*a is *cated in the 0idd*e, 0ist 0ucus 0e06rane, 0ass9$:,

h/pere0ic9$:, *esin9$:.

Phar/n+ 1 Nr0a* phar/n3ea* arch, h/pere0ic9$:, ede0a9$:, 3ranu*atin9$:

Nasopharyngeal laryngoscopy 1 0ass 9$:, 0eatus tu6a eustachius 9/0phadenpath/ cer'ica* */0ph nde 9$:.

2a+i**7acia* 1 s/00etrica* #acial pain on percussion and palpation at a1illary region

6orking diagnosis

Chrnic rhinsinusitis 0a+i**aris de+tra

Di##erential diagnosis

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Suggestion

$ Denta* e+a0inatin

$ Radi*3ic e+a0inatin 94aters psitin:

Therapy$ In7ected tth re0'a*

$ Anti6itics 7r anaer6 6acterias

$ Su33estin 7 =ESS 9=unctina* Endscpic Sinus Sur3er/:


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Rhinosinusitis

De#inition

Rhinsinusitis c0prises a spectru0 7 0edica* cnditins that are characteri8ed 6/

in7*a00atin in the nse and paranasa* sinuses. These are di'ided int acute, su6acute, and

chrnic rhinsinusitis, dependin3 n duratin. Acute sinusitis t/pica**/ *asts ( )eeks r *ess.

Su6acute sinusitis *astin3 ( t & )eeks. Chrnic sinusitis characteri8ed 6/ in7*a00atin

s/0pt0s *astin3 & )eeks r *n3er.

%natoy

Paranasa* sinuses are 0ucsa$*ined structures cntinuus )ith the nasa* ca'it/. The 7unctins

are1

$ Actin3 as resnatin3 cha06ers 7r the 'ice

$ 2isturi8e and hu0idi7/ a06ient air

$ >i3htenin3 the )ei3ht 7 the 7acia* ske*etn

The secretes 7r0ed in the sinuses are drained t their perspecti'e 0eatus. There are three

0eatus, the superir, 0edia, and in7erir 0eatus. The superir 0eatus drains secretes 7r0

the psterir eth0ida* ce**s the 0edia 0eatus thru3h the se0i*unaris hiatus drains secretes

7r0 the 7rnta* sinuses, anterir eth0ida*, and 0a+i**ar/ sinuses and the in7erir 0eatus

drains secretes 7r0 the nas*acri0a* duct.

The ste0eata* c0p*e+ is a s0a** cnstricted re3in )hich is prne t 6structin,

especia**/ in the presence 7 cn3enita* an0a*/9Cncha 6u**sa, septa* de'iatin, septa*

spurs:, in7ectin, tu0rs9p*/p:, trau0a9anat0ic de'iatins, septa* de'iatins:, and

thers9a**er3ic rhinitis, 7rei3n 6dies:

!a1illary Sinus

The 0a+i**ar/ sinus is the pneu0ati8ed space )ithin the 0a+i**ar/ 6ne and is the *ar3est 7

the paranasa* sinuses. The anterir )a** 7r0s the 7acia* sur7ace 7 the 0a+i**a, the psterir

)a** 6rders the in7rate0pra* 7ssa, the 0edia* )a** cnstitutes the *atera* )a** 7 the nasa*

ca'it/, the 7*r 7 the sinus is the a*'e*ar prcess, and the superir )a** ser'es as the r6ita*

7*r. The in7rar6ita* ner'e crsses the r6ita* 7*r t e+it the anterir prtin 7 the 0a+i**a

'ia the in7rar6ita* 7ra0en. The 7irst and secnd 0*ar tth rts are dehiscent int the


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0a+i**ar/ sinus ccurrin3 in 7 cases. These patients are at risk 7r de'e*p0ent 7 an

rantra* 7istu*a 7**)in3 denta* e+tractin at these sites.

"rontal Sinus

The si8e 7 the 7rnta* sinus 'aries dependin3 n the de3ree 7 pneu0ati8atin, 0a/ 6e

c0p*ete*/ a6sent 95:, and is usua**/ di'ided 6/ an intersinus septu0. The anterir ta6*e 7

the 7rnta* sinus is t)ice as thick as the psterir ta6*e, )hich separates the sinus 7r0 the

anterir crania* 7ssa. The 7*r 7 the sinus a*s 7unctins as the suprar6ita* r7, and the

draina3e stiu0 is *cated in the pster0edia* prtin 7 the sinus 7*r. Draina3e 7 the

7rnta* sinus is c0p*e+ )ith its ut7*) tract rese06*in3 an hur3*ass$shaped structure in the

sa3itta* p*ane. The narr)est prtin 7 the ut7*) tract is the 7rnta* stiu0. The superir

prtin )idens int the 7rnta* sinus and the in7erir prtin e+pands int the 7rnta* recess.

The 'aria6i*it/ 7 the 7rnta* sinus ut7*) tract draina3e pattern depends n the

pneu0ati8atin 7 the surrundin3 eth0id air ce**s and the psitin 7 the uncinate prcess.

A 0arked*/ pneu0ati8ed a33er nasi ce** r eth0ida* 6u**a can 6struct 7rnta* sinus

draina3e 6/ narr)in3 the 7rnta* recess. Draina3e 7 the 7rnta* sinus a*s depends n the

attach0ent 7 the superir prtin 7 the uncinate prcess.

Ethoid Sinus

At 6irth, usua**/ three r 7ur ce**s 7 the eth0id sinus are present and, a*n3 )ith the

0a+i**ar/ sinus, are the n*/ sinus ca'ities that are *ar3e enu3h t 6e 7 c*inica*

i0prtance.The ce**s *ie either in 7rnt 7 and 6e*) 9anterir eth0id ce**s: r psterir and

a6'e 9psterir eth0id ce**s: the attach0ent 7 the 0idd*e tur6inate t the *atera* nasa*

)a**. The/ *ie n either side 7 the superir ha*'es 7 the nasa* ca'ities and are separated 7r0

the r6its 6/ the *a0inae pap/raceae. The anterir eth0id ce**s pen int the in7undi6u*u0

7 the 0idd*e 0eatus and the psterir ce**s int the superir 0eatus. The 0idd*e tur6inate

0a/ 6e the site 7 an eth0id ce**, a cncha 6u**sa, )hich can 6struct 7ree sinus draina3e

6ut is usua**/ as/0pt0atic. There are 0an/ 'ariatins 7 pneu0ati8atin 7 the eth0id

ce**s.

Sphenoid Sinus

Pneumatization of the sphenoid bone occurs during middle childhood, proceeding

rapidly after 7 years of age to its nal form at 12 to 15 years (Table 26!"# $achsinus communicates %ith the sphenoethmoidal recess of the superior nasal


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meatus by means of a small aperature of to ! mm# The bony ostium is

usually larger than the membranous and, for gra'ity drainage, is

disad'antageously located 1& to 2& mm abo'e the sinus oor# )e'eral 'ital

structures lie closely ad*acent to the sinus+ the optic ner'e and the hypophysis

abo'e, the pons posteriorly and eternal and lateral to the sinus, the ca'ernous

sinus, the superior orbital ssure, the carotid artery, and se'eral cranial ner'es#

The ner'e of the pterygoid canal ('idian ner'e" may encroach on the sinus oor#

BLOOD SUPPLY OF THE NOSE

The blood supply of the nasal interior comes from the anterior and posterior

ethmoid branches (crossing the ethmoid plate" of the ophthalmic and

sphenopalatine arteries# The latter is the terminal branch of the internal

maillary artery# The anterior and superior portions of the septum and the lateral

%all of the nose recei'e blood 'ia the anterior ethmoid arteries, the smaller

posterior branch supplying only a small posterior region, including the olfactory

area# The internal maillary artery, usually the penultimate branch of the

eternal carotid artery, passes lateral to the pterygoid plate to enter the

pterygoid fossa and continue as the sphenopalatine artery into the nasal ca'ity

by %ay of the sphenopalatine foramen at the posterior end of the middle

turbinate# -ithin the nose, the artery di'ides into posterior lateral nasal and

posterior septal branches that accompany second and third di'isions of the

trigeminal ner'e# There is an anastomosis bet%een the lateral nasal arteries and

the ethmoid. thus, bleeding can arise from either# /ther branches of the

sphenopalatine artery descend in the greater palatine canal to enter the oral

ca'ity and spread o'er the undersurface of the palate# 0eins follo% a course

similar to that of the sphenopalatine artery and drain into the ophthalmic pleus

and partly to the ca'ernous sinus# The nasal 'enous system is %ithout 'al'es

and thus predisposes the spread of infection up%ard to the ca'ernous sinus#

Risk "actors

The anat0ica* a6nr0a*ities such as septa* de'iatin, 6u**a eth0ida*is, cncha 6u**sa,

pr0inent uncinate prcess, narr) 7rnta* recess, and nasa* p*/ps 0a/ 6*ck the sinuses

stia. The cnditins )hich i0pairs the 0ucci*iar/ transprt such as a**er3ic rhinitis, nasa*


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p*/psis, c/stic 7i6rsis, pri0ar/ ci*iar/ d/skinesia, and arta3enerFs r Gun3Fs s/ndr0e.

=ai*ure 7 the 0ucci*iar/ c*earance 7r0 the sinuses thru3h the stia 0a/ *ead t the stasis

and the 7r0atin 7 pus in the sinus. Ci3arrette s0kin3 0a/ a*s a77ect the 0ucci*iar/

c*earance d/s7unctin )hich in turns resu*t in the retentin 7 the secretes in the sinuses.

Pathophysiology

2st 7 the chrnic sinusitis in7ectin is usua**/ 6acteria*, )hich de'e*p secndar/ t the

pri0ar/ 'ira* sinusitis. 4hi*e the acute sinusitis in7ectin is 0st*/ due t the Streptccca*

and ther aer6ic 6acteria, chrnic sinusitis 0ain*/ due t the accu0u*atin 7 anaer6ic

6acteria.

%erobic 7acteria %naerobic bacteriaStreptoccocus Pneumonia

Haemophilus Influenzae

Streptococcus Group A

Moraxella Catarrhalis

Pseudomonas sp.

le!siella sp.

Peptostreptococcus

"acteroides spp.

#uso!acteria

The ri3in 7 the 0a+i**ar/ sinusitis 0a/ 6e either dent3en r rhin3en. The *catin 7 the

a*'e*ar 6ne 7 the tth *ies c*se t the 6ase 7 the 0a+i**ar/ sinus, )hich there7re a**)s

a direct trans0issin 7 0icrr3anis0 7r0 the 0uth t the sinus. Dent3en ri3in usua**/

resu*ts 7r0 the e+tractin 7 the tth )hich accidenta**/ tears the thin 6ne 6et)een the

sinus $ a*'e*ar 6ne and there7re 0akin3 an pen cnnectin 6et)een the ra* ca'it/ and

the 0a+i**ar/ sinus, this is ca**ed the r$antra* 7istu*a.

Rhin3en ri3in is 0st*/ due t the i0paired 'enti*atin 0echanis0 7 the ste0eata* unitsecndar/ t stensis r 6structin 9 s)e**in3 7 the nasa* 0ucsa, 0echanica* 6structin:.

The 7ai*ure 7 the 0ucci*iar/ c*earance )i** resu*t in secrete accu0u*atin )hich 0a/ 6*ck

the sinus penin3s. The 6*cked draina3e 7 the sinus s/ste0 9adjacent 0a+i**ar/ sinus<

anterir eth0ida* ce**s, 7rnta* sinuses: cause the s)e**in3 7 the narr) ste0eata* unit.

This esta6*ish a 'icius c/c*e and 0a/ *ead t recurrent acute in7*a00atin and e'entua**/

the persistent chrnic sinusitis. Chrnic sinusitis 0st*/ a77ect the 0a+i**ar/ sinus and

eth0ida* ce**s, and *ess a77ect the 7rnta* and sphenid sinuses.

6&

ostly dentogen

etoiology


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A. Chnca 6u**sa 9pneu0ati8ed 0idd*e tur6inate:

B. A**er3ic rhinitis, cn3ested h/pere0ic 0ucsa )ith pus

C. Dent3en chrnic sinusitis

D. Nasa* P*/p

Clinical !ani#estation

Patient )ith chrnic sinusitis 0a/ c0p*aint 7 pst nasa* drip, nasa* dischar3e 9usua**/

puru*ent, stink/, and stick/:, du** pain 7 the 7ace r cheek a77ected, headache, s0e 0a/

c0p*ain 7 6structed nasa* 6reathin3. On acute e+acer6atin there 0i3ht 6e 7acia*

cn3estin, pr7use nasa* dischar3e, headache, du** pain in the 7ace, and pst nasa* drip.

P*/p 0a/ 6e seen in ph/sica* e+a0inatin 7 the nasa* ca'it/ 6ased n the 3radin3 7 the

p*/p.

!a8or and !inor "actors %ssociated 5ith the Diagnosis o# Rhinosinusitis:

2ajr 7actrs

3 =acia* pain


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3 dischar3e3 H/ps0ia


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Inc0p*ete treat0ent 7 the sinusitis 0a/ resu*t in the c0p*icatin due t the e+tensin 7

the in7ectin t the adjacent structures1

A. Or6ita* Ce**u*itis

2st*/ ccurs in chi*dren )here the eth0id sinusFs in7ected. In7ectin spreads 7r0

the *a0ina pap/racea int the r6it, passin3 thru3h the 6n/ dehicences r thru3h

the thr6sed c00unicatin3 'esse*s. Initia* 0ani7estatin 0a/ 6e ce**u*itis, then t

the pre septa* in7ectin )hich 0a/ end up )ith pst septa* in7ectin. The 7r0atin 7

a6scess 0a/ i0pair 'isin.

B. 2ucce*e

This resu*ts 7r0 the 6*iteratin 7 the sinus stiu0 and there7re cause the 0ucus

entrap0ent in the sinus. =rnta* and eth0id sinuses 0ucce*e 0a/ cause

disp*ace0ent 7 the 3*6e in7er$*atera**/, dip*pia. 2a+i**ar/ sinus 0ucce*e 0a/

resu*t in s)e**in3 7 the cheek, and sphenid sinus 0ucce*e 0a/ resu*t in cu*0tr

pa*s/.

Treatent

$arly orbital cellulitis 4bscess

formation

aillary )phenoid 8rontal


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Dent3ene Sinusitis shu*d 6e treat 6/ re0'ed the in7ectin tth that cause sinusitis.

Anti6itic is a*s needed, especia**/ 7r anaer6 6acteria1

$ A0+ici**in< c*a'u*anate

$ A*ternati'e 1 2etrnida8*e >e77*+acin

Irri3atin 7 the nasa* ca'it/ )ith ce7ta8idi0e.

The perati'e treat0ent 7 chrnic sinusitis 9a*s )ith the nasa* p*/p: 0i3ht 6e the =ESS

9=unctina* Endscpic Sinus Sur3er/: )hich is *ess in'asi'e and 0a/ 6e satis7actr/.

case sinusitis-dr oscar

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