Meet The Expert

SINUSITIS

Author:
Raudhatul Husnia Agus
Novi Yudia

1010313061
1110313078

Preceptor :
Jacky Munilson, MD, ORL-HN (C)

OTOLARYNGOLOGY HEAD AND NECK DEPARTMENT

MEDICAL FACULTY OF UNIVERSITY OF ANDALAS
DR M DJAMIL HOSPITAL
2016

Preface
Praise and thanks to Allah SWT, which has bestowed His mercy and grace
so we finished the literature review entitled "Sinusitis" in accordance with a
predetermined time. This literature review was written to increase knowledge and
insight about sinusitis, as well as being one of the conditions in completing the
tasks as a senior clerkship in Otolaryngology Head and Neck department, Dr.
M.Djamil Hospital, Faculty of Medicine, University of Andalas.
We thank all those who have helped us when preparing this literature
review, especially to Jacky Munilson, MD, ORL-HN (C) as our preceptor who
was willing to take his time and give advice and guidance to us. We also like to
thank my fellow young doctors and all those who have helped in the preparation
of this literature review that we can not mention one by one here.
Thus, we hope that this literature review can add, insight, knowledge, and
enhance in understanding of sinusitis.
Padang, October 2016

Author

Chapter 1
Introduction
1.1.

Background
Sinuses are hollow spaces in the bones around the nose that connect to the
nose through small, narrow channels. The sinuses stay healthy when the
channels are open, which allows air from the nose to enter the sinuses and
mucus made in the sinuses to drain into the nose. Sinusitis, also called
rhinosinusitis, affects about 1 in 8 adults annually and generally occurs when
viruses or bacteria infect the sinuses (often during a cold) and begin to
multiply. Part of the bodys reaction to the infection causes the sinus lining to
swell, blocking the channels that drain the sinuses. This causes mucus and pus
to fill up the nose and sinus cavities.
Clinical findings in acute sinusitis may include pain over cheek and
radiating to frontal region or teeth, increasing with straining or bending down,
redness of nose, cheeks, or eyelids, tenderness to pressure over the floor of the
frontal sinus immediately above the inner canthus, referred pain to the vertex,
temple, or occiput, postnasal discharge, a blocked nose, persistent coughing or
pharyngeal irritation, facial pain, and hyposmia. The primary goals of
management of acute sinusitis are to eradicate the infection, decrease the
severity and duration of symptoms, and prevent complications. Most patients
with acute sinusitis are treated in the primary care setting.

1.2.

Problems Limitation
1

Problem limitation of writing this literature review is the definition,

epidemiology, etiology and risk factors, classification, pathogenesis, clinical
manifestations, diagnosis, management of, and complications of sinusitis.
1.3.
The benefits of writing
The benefits of clinical science writing this literature review is to increase
knowledge about the definition, epidemiology, etiology and risk factors,
classification, pathogenesis, clinical manifestations, diagnosis, management
of, and complications of sinusitis.
1.4 Method of Writing
The writings are based on the review of literature to refer to some of the
existing literature.

Chapter 2
Literature Review

2.1. Anatomy of sinus paranasal

The paranasal sinuses form a complex unit of four paired air-filled cavities
at the entrance of the upper airway. They start developing from ridges and furrows
in the lateral nasal wall as early as the eighth week of embryogenesis, and they
continue their pneumatization until early adulthood. Each one is named after
2

the skull bone in which it is located.1

Figure 2.1. Anatomy of sinus paranasal

However, during the development of a sinus, pneumatization may involve
adjacent bones, as is the case for the ethmoid sinus developing into the frontal,
maxillary or sphenoid bone, and for the maxillary sinus extending into the
zygomatic bone. All sinuses are lined by a respiratory pseudostratified epithelium,
composed of four major types of cells2:
a.
b.
c.
d.

Ciliated columnar cells

Nonciliated columnar cells
Goblet type mucous cells
Basal cells

This mucosa is directly attached to bone and is referred to as mucoperiosteum.

Although it is somewhat thinner, the mucoperiosteum of the sinuses is continuous
with that of the nasal cavity through the various ostia of the sinuses. The ostium is
a natural opening through which the sinus cavity drains into the airway, either
directly into the nasal cavity (i.e., sphenoid ostium), or indirectly by means of
3

more complex anatomical structures (i.e., frontal recess). The most important
progress offered by the concept of functional ESS compared with older surgical
approaches to the paranasal sinuses is the acknowledgement of the essential role
of the sinus ostia and mucosa in the surgical management of inflammatory disease
of the paranasal sinuses. By achieving an adequate drainage around the natural
ostium, the mucosal disease and subsequent symptoms could become reversible in
many cases.2 The paranasal sinuses composed of:
a. The frontal sinuses
The frontal sinuses are contained in the frontal bone. They vary
greatly in size and one or both are occasionally absent. In section each is
roughly triangular, its anterior wall forming the prominence of the
forehead, its posterosuperior wall lying adjacent to the frontal lobe of the
brain, and its floor abutting against the ethmoid cells, the roof of the nasal
fossa and the orbit. The frontal sinuses are separated from each other by a
median bony septum, and each in turn is further broken up by a number of
incomplete septa. Each sinus drains into the anterior part of the middle
nasal meatus via the infundibulum into the hiatus semilunaris2
b. The maxillary sinus (antrum of Highmore)
This is a pyramidal-shaped sinus occupying the cavity of the
maxilla. Its medial wall forms part of the lateral face of the nasal cavity
and bears on it the inferior concha. Above this concha is the opening, or
ostium, of the maxillary sinus into the middle meatus in the hiatus
semilunaris. This opening, unfortunately, is inefficiently placed as an
adequate drainage point. The infra-orbital nerve lies in a groove which

bulges down into the roof of the sinus, while its floor bears the
impressions of the upper premolar and molar roots. These roots are
separated only by a thin layer of bone which may, in fact, be deficient so
that uncovered dental roots project into the sinus. Note that the floor of the
sinus, therefore, corresponds to the level of the alveolus and not to the
floor of the nasal cavity it actually extends about 0.5in (12mm) lower
than the latter. 2

Figure 2.2. The maxillary antrum in coronal section. (Note the

inefficient drainage of this antrum and its close inferior
relationship to the teeth.)

Figure 2.3. The corresponding CT scan.

c. The ethmoid sinuses
The ethmoid sinuses are made up of a group of 810 air cells within
the lateral mass of the ethmoid and lie between the side-walls of the upper
nasal cavity and the orbits. Superiorly, they lie on each side of the
cribiform plate and are related above to the frontal lobes of the brain.
These cells drain into the superior and middle meatus. The ethmoid
sinuses arise in the ethmoid bone, forming several distinct air cells
between the eyes. They are a collection of fluid-filled cells at birth that
grow and pneumatize until the age of 12. The ethmoid cells are shaped like
pyramids and are divided by thin septa. They are bordered by the middle
turbinate medially and the medial orbital wall laterally. The ethmoid
labyrinth may extend above the orbit, lateral and superior to the sphenoid,
above the frontal sinus, and into the roof of the maxillary sinus.

The ethmoid sinuses are supplied by the anterior and posterior

ethmoidal arteries from the ophthalmic artery (internal carotid system), as
well as by the sphenopalatine artery from the terminal branches of the
internal maxillary artery (external carotid system).
d. The sphenoid sinuses
These lie one on either side of the midline, within the body of the
sphenoid. They vary a good deal in size and may extend laterally into the
greater wing of the sphenoid or backwards into the basal part of the
occipital bone. Each sinus drains into the nasal cavity above the superior
concha (the sphenoethmoidal recess).

e. Osteomeatal Complex
The term ostiomeatal unit represents 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 antomically
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). The boundaries of sinus
paranasal are:
a. Medially: Middle turbinate
b. Laterally: Lamina papyracea

c. Superiorly and posteriorly: Basal lamella

d. Inferiorly and anteriorly: It is open

Figure 2.4. Osteomeatal Complex

Functionally, significant structures of the Ostiomeatal complex are:
a. Uncinate process (Hook like bony extension of medial
wall)
b. Hiatus semilunaris (Crescent passage between uncinate
process and ethmoid bulla through which middle meatus
communicates with ethmoidal infundibulum)
c. Frontal recess (Drainage channel of frontal sinus)
d. Bulla ethmoidalis (most constant and largest anterior
ethmoid air cell that projects inferomedially over hiatus
semilunaris)
e. Ethmoidal infundibulum (Funnel shaped passage through
which anterior ethmoid cells and maxillary sinus drains into
middle meatus)
8

f. Maxillary sinus ostium (Drainage channel of maxillary

sinus)3
2.2. Physiology of sinus paranasal
No conclusive theory on the role of paranasal sinuses has been accepted
yet. Some authors have suggested a functional role, while others have argued that
the paranasal sinuses in higher primates are merely nonfunctional remnants of a
common mammalian ancestor. The following sections review the different
theories.4
a. Lighten the Skull for Equipoise of the Head
This is the oldest of all theories. The first objection came from
Braune and Clasen (1877), who claimed that if the sinuses were filled with
spongy bone the total weight of the head would be increased by only 1%.
Despite statements that mans musculature is adequate to maintain head
poise regardless of the state of paranasal sinuses, it was not until 1969 that
an electromyographic investigation was made of the activity of human
neck muscles in response to loading the anterior aspect of the head. It was
concluded that the human paranasal sinuses are not signifi cant as weight
reducers of the skull for maintenance of equipoise of the head.4,5
b. Impart Resonance to the Voice
In the seventeenth century, Bartholinus asserted that paranasal
sinuses are important phonatory adjuncts in that they aid resonance. This
stated that the peculiar quality or timbre of the individual voice arises from
the accessory sinuses and the bony framework of the face. Nevertheless, a
few authors discounted the resonance theory by observing that animals

with loud voices such as the lion can have small sinuses or that other
animals, such as the giraffe and rabbit, have small or shrill, non-resonant
voices despite having large sinus cavities. Finally, Flottes et al. (1960)
reported that the physical properties

make them poor resonators and

added that sinus surgery does not modify the voice.5

c. Increase the Olfactory Area
This theory stated that the human maxillary sinus was lined with
olfactory epithelium such as in some mammals. On the contrary, the
mucous membrane of the human paranasal sinuses is made up of nonolfactory epithelium, but is lined by a thinner, less vascular mucosa which
is more loosely fixed to the bony wall than that of the respiratory region of
the nasal cavity.4
d. Thermal Insulation of Vital Parts
This theory was originally proposed by Proetz (1953) who
compared the paranasal sinuses to an air-jacket enveloping the nasal
fossae. Nevertheless, Eskimos often possess no frontal sinus, while
African Negroes possess large frontal sinuses.4
e. Secretion of Mucus to Moisten the Nasal Cavity
This theory is also discounted on the basis of histology. First
advocated by Haller (1763, reported by Wright 1914) it proposes that the
sinuses are important for moistening the nasal olfactory mucosa. However,
scientist observed that an adequate amount of mucus for this purpose
cannot be secreted by the human paranasal sinuses lining. In contrast to

10

the nose with its 100,000 submucosal glands, the sinuses have only 50
100 glands.5
f. Humidify and Warm the Inspired Air
It has long been known that air exchange takes place in the sinuses
during respiration. However, a debate existed as to whether this exchange
occurs to enable humidification and warming of inspired air. Aerated
sinuses develop in large swiftly moving mammals with an active
respiration, while slow moving mammals, especially those living in a
humid medium like the hippopotamus, have small sinuses. However, some
authors demonstrated that exchange of gases between the nose and
paranasal sinuses is negligible and thus also the contribution of the sinuses
to the conditioning of the inspired air proves to be insignificant.6
2.3. Sinusitis
Inflammation of the paranasal sinuses can be infectious or noninfectious.
Because of the almost universal involvement of the nose in inflammatory sinus
conditions, the term rhinosinusitis (RS) instead of sinusitis was recommended by
the 1997 Task Force of the Rhinology and Paranasal Sinus Committee.
Rhinosinusitis can be categorized as acute (less than 4 weeks in duration),
subacute (more than 4 weeks but less than 12 weeks), and chronic (more than 12
weeks). The vast majority of infectious causes of RS are acute, self-limited viral
events, also known as the common cold. Fewer than 2% of colds in adults and up
to 30% of colds in children progress to bacterial RS. The causes of chronic
rhinosinusitis (CRS) are multiple and include infectious (viral, bacterial, and
fungal), allergic, anatomic, mucociliary, (e.g., cystic fibrosis, primary or acquired
11

ciliary dyskinesia), and systemic disorders. CRS is less frequently bacterial in

etiology and is most broadly subdivided into categories of patients with
hyperplastic mucosal changes with polyps and those without polyps. 7
2.3.1. Definition
Sinusitis, also known as rhinosinusitis, is inflammation of the
paranasal sinuses. It can be due to infection, allergy, or autoimmune
problems. Most cases are due to a viral infection and resolve over a course
of 10 days. It is a common condition, with over 24 million cases in the
Unites States. Inflammation of the paranasal sinuses can be infectious or
noninfectious. Because of the almost universal involvement of the nose in
inflammatory sinus conditions, the term rhinosinusitis (RS) instead of sinusitis
was recommended by the 1997 Task Force of the Rhinology and Paranasal Sinus
Committee.8,9
2.3.2. Epidemiology

In spite of these problems, some data are available. In the USA the
prevalence of sinusitis is estimated to be 14% of the global population. In
1979 Albegger calculated the prevalence of sinusitis in a general
population to range from 32% in young children to 5% in adults. In the
USA chronic sinusitis accounted for 24 million patient visits in 1992 (an
increase of eight million compared with 1989). The primary care physician
was the first line practitioner in 85% of cases; 97% of the patients who
visited their physicians with sinusitis (in 1992) received a prescription. A
total of $200 million was spent on the treatment of chronic sinusitis. It
seems that the prevalence of sinusitis is increasing. Between 1990 and
12

1992 patients with sinusitis in the USA reported approximately 73 million

days of restricted activity, an increase from the 50 million days reported
between 1986 and 1988. In 1998 Beauvillain de Montreuil reported, in a
multivariate analysis, that chronic bronchitis, corticosteroids, atopy,
occupational rhinitis, and local decongestants were the most important
factors influencing the transformation to a chronic form of sinusitis.
Patients with particular diseases develop sinusitis more oftenfor
example, 2530% of allergic patients, 43% of asthmatic patients, 37% of
patients with transplants, and 5468% of patients with AIDS.10
Chronic nasal complaints in children under the age of eight years
represent about 24% of the total number of outpatient visits to an average
Dutch ENT practice. The diagnosis of chronic sinusitis in young children
is, however, difficult to establish on clinical grounds alone. The use of
imaging is frequently used where there is a suspicion of sinusitis in the
paediatric population.10
2.3.3. Etiology
The nasal cavity is heavily colonized with respiratory flora, which
can easily contaminate materials obtained from paranasal sinuses. In
classic studies of the bacteriology of sinusitis, specimens of sinus
secretions were obtained by puncture of the maxillary antrum to reduce the
risk of nasal contamination. Infection is defined as bacterial colony count
of at least 104 colony-forming units per milliliter (CFU/ml) of aspirated
materials.9

13

Acute sinusitis is usually precipitated by an earlier respiratory tract

infection, generally of viral origin, mostly caused by rhinoviruses,
coronaviruses, and influenza viruses, other caused by adenoviruses ,human
para influenza viruses, human respiratory syncytial virus, enteroviruses
other than rhinoviruses, and metapneumovirus. If the infection is of
bacterial origin, the most common three causative agents are
Streptococcus

pneumoniae,

Haemophilus

influenza,

and

Moraxellacatarrhalis. Until recently Haemophilus influenza was the most

common bacterial agent to cause sinus infections.However, introduction of
H.influenzae type B(Hib) vaccine has dramatically decreased H.influenzae
type B infections and now non-type H.influenzae (NTHI) are
predominantly seen in the clinics. Other sinusitis-causing bacterial
pathogens include Staphylococcus aureus and other streptococci species,
anaerobic bacteria and less commonly, gram negative bacteria. Viral
sinusitis typically lasts for 7 to 10 days whereas bacterial sinusitis is more
persistent. Approximately o.5% to 2% of viral sinusitis results in
subsequent bacterial sinusitis. It is thought that nasal irritation from nose
blowing leads to the secondary bacterial infection.9
Acute episodes of sinusitis can also result from fungal invasion.
These infections are typically seen in patients with diabetes or immune
deficiencies (e.g., AIDS or transplant patients on immunosuppressive anti
rejection medication) and can be life threatening. In type 1 diabetics,
ketoacidosis can be associated with sinusitis due to mucromycosis.
Aspergillus, Bipolaris, Curvularia and Exserohilum have been associated

14

with fungal sinus disease. Chemical irritation can also trigger sinusitis,
commonly from cigarette smoke and chlorine fumes. Rarely, it may be
caused by a tooth infection.9
Chronic sinusitis represents a multifactorial inflammatory disorder,
rather than simply a persistent bacterial infection. A combination of
anaerobic and aerobic bacteria, are detected in conjunction with chronic
sinusitis. Also isolated are Staphylococcus aureus (including methicillin
resistant S.aureus-MRSA) and coagulase-negative Staphylococci and
Gram negative enteric organisms can be isolated. Attempts have been
made to provide a more consistent nomenclature for subtypes of chronic
sinusitis.The presence of eosinophils in mucous lining of the nose and
paranasal has been demonstrate for many patients, and this has termed
eosinophilic mucin rhinosinusitis(EMRS).Cases of EMRS may be related
to an allergic response, but allergy is not often demonstrated, resulting in
further subcategorization into allergic and non-allergic EMRS.9
A more recent, and still debated, development in chronic sinusitis
is the role that fungi play in this disease. It remains unclear if fungi are
definite factor in the development of chronic sinusitis and if they are, what
the difference may be between those who develop the disease and those
who remain free of symptoms. Trials of antifungal treatments have mixed
results.9
2.3.4. Risk Factor
Age, allergic rhinitis, atopy, and asthma seem to be predisposing
factors for chronic and recurrent RS. Adenoid hypertrophy was most

15

prevalent in chronic RS. There is currently no information regarding

predisposing factors for chronic and recurrent rhinosinusitis (RS),
although these are considered to be multifactorial in origin, and allergic
diseases contribute to their pathogenesis.11

Figure 2.5. Predisposing factor in Sinusitis

2.3.5. Classification
Sinusitis is classified into two category based on the duration of the
symptom.
a. Acute sinusitis
Acute sinusitis is a bacterial infection of the paranasal sinuses lasting less
than 4 weeks, often heralded by an increase in symptoms during the
second week of an upper respiratory tract infection when the sore throat
and laryngeal and lower respiratory symptoms are beginning to resolve.
The presence of sinonasal congestion, facial pain, headache, and
mucopurulent drainage is an indication that bacterial rhinosinusitis has
16

resulted from the viral infection.

b. Chronic Sinusitis
Chronic sinusitis is defined as an infection causing sinonasal symptoms
for more than 3 months; it is more often a result of an acquired or
congenital anatomic abnormality than is acute sinusitis. Chronic infection
may cause long-lasting changes in the mucosa and the bony walls of the
sinuses, leading to an entrenched disease process. Surgery is often
indicated for the treatment of chronic sinusitis refractory to aggressive
medical therapy.12
2.3.6. Pathogenesis
Pathogenesis of rhinosinusitis involves three key elements: narrow
sinus ostia, dysfunction of the ciliary apparatus, and viscous sinus
secretions. The narrow caliber of the sinus ostia sets the stage for
obstruction to occur. Factors that predispose the ostia to obstruction
include those that result in mucosal swelling and those that cause direct
mechanical obstruction of these multiple causes viral upper respiratory
infection (URI) and allergic inflammation are the most frequent and most
important. During episodes of acute rhinitis, a completely patent ostia is
present only 20% of time. When obstruction of sinus ostium occurs, there
is transient increase in pressure within the sinus cavity. As oxygen is
depleted in this close space, the pressure in the sinus becomes negative
relative to atmospheric pressure. This negative pressure may allow the
introduction of nasal bacteria into sinuses during sniffing or nose blowing.
When obstruction of the sinus ostium occurs, secretion of mucous by
mucosa continues, resulting in accumulation of fluid in the sinus.10

17

Figure 2.7. Sinus Drainage

Figure 2.8. Sinusitis cycle

A study of adult volunteers investigated the role of nose blowing in
introducing nasal fluid, and possibly microbes with the fluid, into the sinus
18

cavities. Serial computed tomography (CT) scans showed that up to 1 ml

of viscous fluid was propelled into the sinus when volunteers blew their
noses. This one potential mechanism for nasal fluid and flora to
contaminate the sinuses, particularly during common cold. However,
young children who do not blow their noses still develop acute bacterial
sinusitis, so there must be multiple factors that play a role in the
development of acute infection.10
Dysfunction of mucocilary apparatus also contributes to the
pathogenesis of sinusitis. During viral colds, both the structure and the
function of the mucociliary apparatus are impaired. In a study of children
with viral URI, nasal mucosal biopsies were performed for the
examination of the ultrastructure of the cilia. Dysmorphic ciliary forms
involving micro tubular abnormalities were observed during the acute
phase(7days) of illness. Progressive loss of ciliated cells was observed
throughout the illness in a patch pattern. In a study of documented
viralURI in adults. mucociliary clearance was measured with the use of a
solution of dyed saccharin. Mucociliary clearance times, measured by taste
and color, were significantly slower during acute phase of illness.
Presumably these same changes in structure and function of the nasal
mucosa during viral URI occur also in the sinus mucosa. This attributes to
the reduced clearance of material and increases the likelihood of sinus
cavity. The quality and characters of sinus secretions also play a role in the
pathogenesis of sinusitis. Cilia can beat only in fluid media. The mucous
blanket in the respiratory tract consists of two layers. The sol phase is thin,

19

low-viscosity layer that envelops the shaft of the cilia and allows the cilia
to beat freely. A more viscous layer, the gel phase, rides on sol phase.
Alterations in the mucous layer, which occur in the presence of
inflammatory debris, as in infected sinus, may further impair ciliary
movement.10
Historically, it was believed that a reduction in airflow through the
nasal passages contributes to the development of rhinosinusitis. However,
an extensive review of this hypothesis found no convincing evidence that
diminished airflow is a factor in sinus pathology. Except in experimental
models; the histological findings during acute sinusitis were not well
characterized until recently. In the rabbit model of acute sinusitis,
histological changes include epithelial desquamation edema, and goblet
cell hyperplasia. Of note is the distinct loss of ciliated cells from the
epithelium, Berger and colleagues examined biopsies of 11 humans who
had acute sinusitis and surprisingly, found that epithelial layer of sinus
remained intact. In contrast, the lamina propria showed edema and
massive infiltration of neutrophils and mononuclear cells, including
lymphocytes and plasma cells.Occasionally aggregates of inflammatory
cells with micro abscesses were also detected. Thrombosed blood vessels
and deep necrotic foci were observed in patients with complications of
acute sinusitis. Immunohistologic staining showed T lymphocytes
scattered throughout the lamina propria , with dense aggregates of B
lymphocytes. An analysis of cytokine production in sinusitis showed that
interleukin-8 (IL-8), a potent chemoattractant for neutrophils, is

20

upregulated in the sinus during acute infection. In patients with acute

sinusitis, healing of mucous occurs over a period of weeks after infection.
In a study in which serial magnetic resonance imaging was performed in
patients with acute bacterial sinusitis, clinical symptoms resolved within
three days of treatment in most patients. Radiographic changes took much
longer to show improvement, with only half of the sinuses showing
resolution of opacification by 10 days. It took up to 56 days for 80% of the
sinuses to be aerated.10
It has been hypothesized that biofilm bacterial infections may
account for many cases of antibiotic refractory chronic sinusitis. Biofilms
are complex aggregates of extracellular matrix and interdependent
microorganisms from multiple species, many of which may be difficult or
impossible to isolate using standard clinical laboratory techniques.
Bacteria found in biofilms have their antibiotic resistant increased up to
1000 times when compared to free living bacteria of same species. A
recent study found that biofilms were present on mucosa of 75% of
patients undergoing surgery for chronic sinusitis.10
2.3.7. Clinical Manifestation
1)
Acute Rhinosinusitis
Symptom
The subjective assessment of ARS is based on the presence
a.

and severity of symptoms.13

Nasal blockage, congestion or stuffiness
Although nasal obstruction can be assessed objectively with techniques
such as rhinomanometry, nasal peak inspiratory flow and acoustic rhinometry,
these are rarely used in the diagnosis and assessment of ARS, which relies on
patient report of obstruction and subjective assessment of severity, either by

21

b.

VAS score or by assessing obstruction as absent, mild, moderate or severe.

Nasal discharge or postnasal drip, often mucopurulent
Patient reported purulence of nasal discharge has been recommended as a
diagnostic criterion for acute bacterial rhinosinusitis, and is prioritized by
GPs as a feature indicating the need for antibiotics, with limited evidence to
support this. Purulent nasal secretions have been reported to increase the
likelihood ratio of radiological sinus opacity, and of obtaining a positive
bacterial

culture,

although

purulent

rhinorrhoea

with

unilateral

predominance has a positive predictive value (PPV) of only 50%, and pus in
the nasal cavity a PPV of only 17%, in the prediction of a positive bacterial
culture of an aspirate of the maxillary sinus, so cannot be relied upon to
c.

accurately identify bacterial infection

Facial pain or pressure, headache
Facial pain and pressure commonly occur in ARS, although may also
occur transiently in self-limiting viral upper respiratory tract infection
(URTI). Facial or dental pain, especially when unilateral, has been found to
be a predictor of acute maxillary sinusitis with fluid retention in patients with
suspected bacterial infection when confirmed by maxillary antral aspiration
or paranasal sinus radiographs. Pain on bending forwards and maxillary
toothache, particularly when unilateral, are often interpreted by GPs as
indicative of more severe disease and the need for antibiotics, with limited
supportive evidence. A further study reported that maxillary toothache was
significantly associated with the presence of a positive bacteriological culture,
predominantly of S. pneumoniae or H. influenzae, obtained by sinus

d.

aspiration or lavage.
Reduction/loss of smell
Reduction of smell can be rated by patient subjective report as a VAS

22

score or assessed as absent, mild, moderate, or severe. Subjective report of

olfaction correlates well with objective tests (243-245) and loss of olfaction is
commonly associated with ARS.
Distant symptoms are pharyngeal, laryngeal, and tracheal irritation causing
sore throat, dysphonia, and cough, and general symptoms including drowsiness,
malaise, and fever. There is little reliable evidence of the relative frequency of
different symptoms in ARS in community practice. In patients with a suspicion of
infection, facial or dental pain (especially if unilateral) have been found to be
predictors of acute maxillary sinusitis, when validated by maxillary antral
aspiration or paranasal sinus radiographs. The symptoms of ARS occur abruptly
without a history of recent nasal or sinus symptoms. A history of sudden
worsening of preexisting symptoms suggests an acute exacerbation of chronic
rhinosinusitis, which should be diagnosed by similar criteria and treated in a
similar way to ARS.
-

a.

Clinical examination13,14

Temperature
The presence of a fever of >38C indicates the presence of a more severe
illness and the possible need for more active treatment, particularly in
conjunction with more severe symptoms. A fever of >38C is significantly
associated

with the presence of a positive

bacteriologic

culture,

predominantly S. pneumoniae and H. influenzae, obtained by sinus aspiration

or lavage
b. Inspection and palpation of sinuses
Inspection and palpation of the maxillofacial area can reveal swelling and
tenderness, which are commonly interpreted as indicating more severe
23

disease and the need for antibiotics, although the sensitivity and specificity of
this symptom in the identification of ABRS is not established.
c. Anterior rhionoscopy
Although anterior rhinoscopy alone is a very limited investigation, it
should be performed in primary care setting as part of the clinical assessment
of suspected ARS. It may reveal supportive findings such as nasal
inflammation, mucosal oedema and purulent nasal discharge, and can
sometimes reveal previously unsuspected findings such as polyps or
anatomical abnormalities.
2)
Chronic Rhinosinusitis13,14
Symptoms
An overlap of symptoms with ARS, those of chronic
rhinosinusitis are typically of lesser intensity. In addition to the
diagnostic symptoms listed above, there are several minor
symptoms including ear pain or pressure, dizziness, halitosis,
dental pain, distant and general symptoms including nasal,
pharyngeal, laryngeal and tracheal irritation, dysphonia and cough,
drowsiness, malaise and sleep disturbance, presenting in numerous
combinations in a study using the Cologne questionnaire, the
most commonly reported symptoms of CRS were nasal obstruction
(92%), postnasal drip (87%) and dry upper respiratory tract
a.

syndrome (68%) and facial pain

Nasal obstruction
Nasal obstruction is one of the most commonly reported symptoms of
CRS. It consists of 3 main components; congestion due to dilation of the
venous sinusoids as a result of inflammation and oedema, nasal fibrosis
and nasal polyposis, and may only be partly reversible by topical

24

decongestant
b. Nasal discharge
Nasal discharge may be anterior or posterior, and may vary greatly in
composition. Patients may report profuse watery discharge or thick
purulent secretions.
c. Facial pain
d. Olfactory disturbance
Olfactory disturbance is common, due to physical prevention of
odorants reaching the olfactory cleft, and oedema in this area. A recent
population-based epidemiological study found that a history of nasal
polyps was a significant risk factor for olfactory impairment.
Clinical examiniation
a. Anterior rhinoscopy
Anterior rhinoscopy alone is of limited value, but nonetheless, remains the
first step in examining a patient with these diseases.
b. Nasal endoscopy
This may be performed without and with decongestion and semi-quantitative
scores for polyps, oedema, discharge, crusting and scarring (post-operatively)
can be obtained at baseline and at regular intervals following therapeutic
interventions eg at 3, 6, 9 and 12 months.
2.3.8. Diagnosis13
1) Acute rhinosinusitis
Acute rhinosinusitis in adults is defined as a sudden onset of two or
more

symptoms,

one

of

which

should

be

either

nasal

blockage/obstruction/congestion or nasal discharge (anterior/ posterior

nasal drip) for <12 weeks:
facial pain/pressure,
reduction or loss of smell;
This may be supported by endoscopic signs of purulent
discharge from the middle meatus, oedema/ mucosal obstruction
primarily in the middle meatus Imaging is rarely performed except in
severe/complicated cases
2) Chronic Rhinosinusitis
25

Chronic rhinosinusitis, with or without nasal polyps in adults is

defined as for 12 weeks :
inflammation of the nose and the paranasal sinuses characterised
by two or more symptoms, one of which should be either nasal
blockage/obstruction/congestion

or

nasal

discharge

(anterior/posterior nasal drip):

facial pain/pressure
reduction or loss of smell

This should be supported by demonstrable disease Either endoscopic

signs of:
nasal polyps, and/or
mucopurulent discharge primarily from middle meatus and/or
oedema/mucosal obstruction primarily in middle meatus and/or
CT changes: mucosal changes within the ostiomeatal complex
and/or sinuses
2.3.9.Treatment
The goal of therapy for sinusitis include speeding up the healing process,
prevent complications, and prevent the course of the disease becomes chronic.
The principle of treatment is open blocked KOM so that the drainage of the
sinuses naturally recover.4 Paranasal sinus ventilation and drainage can be
improved by giving a decongestant nasal drops, nasal spray, or put a wet cotton
with nose drops to media meatus.15
Antibiotics and decongestants is the treatment of choice in acute bacterial
sinusitis, to eliminate the infection and swelling of the mucosa and open blocked
sinus ostium. Antibiotics chosen was the penicillins such as amoxisilin. If the
bacteria are resistant or to produce beta-lactamase, it can be given amoxisilinclavulanate or type 2nd generation cephalosporins. In sinusitis antibiotics are

26

given for 10-14 days although clinical symptoms have been lost.16
Antibiotics is the key in the management of acute suppurative sinusitis.
Amoxicillin is the right choice for gram positive and negative bacteria.
Vancomycin for S. pneumoniae bacteria resistant to amoxicillin. Selection of
other first-line therapy is a combination of erythromycin and dulfonamide or
cephalexin and sulfonamide.14
Parenteral antibiotics given to sinusitis who have experienced complications such
as complications of orbital and intracranial complications, because it can penetrate
the blood-brain barrier. Ceftriaxone is a good choice because in addition to
eradicate all bacteria related causes sinusitis, the ability to penetrate the blood
brain barrier is also good.14
In sinusitis caused by anaerobic bacteria can be used metronidazole or
clindamycin. Clindamycin can penetrate the cerebrospinal fluid. Antihistamines
only given to sinusitis with allergic predisposition. Analgesics can be given. Warm
compresses can also be done to reduce the pain.14
Conservative treatment options provide a decongestant nasal drops (no more
than 1 week), and a broad-spectrum antibiotic (eg, amoxicillin) for sinusitis and
acute exacerbations with fever malaise.Mukolitik can be given as supportive
therapy. In allergic sinusitis etiology can be given anti-allergic. All conservative
therapies only address the symptoms and not be able to eliminate the cause of
chronic sinusitis. Definitive therapy is sinus surgery.17
Functional endoscopic sinus surgery (BSEF / FESS) is the latest surgery for
chronic sinusitis that requires surgery. This action nearly replaced all previous
types of sinus surgery because it provides a more satisfactory results and actions

27

are lighter and not radical. The indications such as chronic sinusitis that does not
improve after adequate treatment; Chronic sinusitis accompanied by cysts or
abnormality is irreversible; extensive polyps, sinusitis any complications.16
a. Acute rhinosinusitis
For treatment evidence and recommendations for acute rhinosinusitis
see figure 2.9 Initial treatment depending on the severity of the disease
(See Figure 2.9):13
Mild (viral, common cold): start with symptomatic relief
(analgetics,

saline

irrigation,

decongestants,

herbal

compounds);
Moderate (postviral): additional topical steroids
Severe (including bacterial): additional topical steroids,
consider antibiotic.

Figure 2.9 Management Scheme for primary care for adults with acute sinusitis13

b. Chronic rhinosinusitis
For treatment evidence and recommendations for acute
28

rhinosinusitis see figure 2.10 (primary care and non-ENT specialist) ,

figure 2.10 ( CRsNP) and figure 2.11 (CRSwNP).

Figure 2.10 Primary care and non-ENT specialist13

29

30

2.3.10. The other examination

The Other examination are plain radiography or CT scan. Plain
radiographs position Waters, PA and lateral, generally only able to assess the
condition of the sinuses - maxillary sinus such large and frontal sinus. The
disorder will be seen in the form of perselubungan, limit air and liquid (water
fluid level) or mucosal thickening.16

31

Sinus CT scan is the gold standard for the diagnosis of sinusitis is able to
assess the anatomy of the nose and sinus disease in the nose and sinuses as a
whole and its expansion. But because of expensive examination, CT Ssan only be
undertaken as supporting the diagnosis of chronic sinusitis that does not improve
with treatment or when performing preoperative sinus surgery.16

Figure 2.12. Normal CT scan of the paranasal sinuses in pieces Coronal and
Sagittal.18

32

Figure 2.13. CT scan of the paranasal sinuses and ethmoid Acute maxillary
sinusitis in pieces Coronal and Axial18
Microbiological examination and resistance tests carried out by taking
secretions from the media or superior meatus, to get the appropriate antibiotics.
Better yet when taken secretions out of the maxillary sinus puncture.16
Sinuskopi done with puncture penetrate through the medial wall of the
maxillary sinus inferior meatus, by means of an endoscope can be seen that the
actual condition of the maxillary sinus, which can be done for the treatment of
sinus irrigation.16
2.3.11. Complication
Complications of rhinosinusitis is classified into orbital complications, osseous
(bone) and intrakranial, though rarely.13,16
1. Orbital complication
Sinusitis complications involving the eyes are common, especially
in etmoiditis, while the sphenoid rare infection. Expansion of the
infection directly and often through the lamina papirasea or through a
vein.13,17
Orbital complications, especially in children, often come without
pain. Orbital manifestations such as swelling, eksophtalmus, and
33

movement disorders (extraocular) eye. Periorbital or orbital cellulitis

can happen directly or through the vascular expansion sinus infection.
Initial manifestation in the form of edema and erythema at the medial
eyelid. If the extension of infection from maxillary sinus and the
frontal sinus edema / swelling occurs in the lower or upper eyelids. 13
2. Intracranial compllication
Including epidural abscess, subdural, brain abscess, meningitis (the
most common), cerebritis and sinus thrombosis cavernosa. 4.12
Clinical symptoms of all these complications are not specific, high
fever, migraine or retro-orbital frontal, common signs of meningeal
irritation and varying degrees of mental status changes. Meanwhile,
intracranial abscess is often preceded by signs of increased intracranial
pressure, irritation / meningeal stimulation ldan focal neurological
deficits.13
Endokranial Complications most often associated with ethmoidal or
frontal rhinosinusitis. Infections can progress of the paranasal cavities
to intracranial structure in two different ways: pathogens, ranging from
the most common frontal sinus or ethmoid sinus, can pass diploic vein
to reach the brain, the other way, pathogens can reach the intracranial
structures with sinus bone eroding. 13
3. Osseous complication
A sinus infection can also expand to the bones becoming
osteomyelitis and eventually involving the brain and nervous system.
Despite the spread of intracranial most often is due to frontal sinusitis,
sinus infections can also cause other complications. 7.12 The most
common complication is osteomyelitis of the maxilla bone (usually in
infancy) or frontal. 13,17
34

2.3.12. Prognosis
Prognosis of acute sinusitis is very good, with about 70% of patients
recover without treatment. Oral antibiotics may reduce symptoms of sinusitis.
Chronic sinusitis have a disease that varies. The prognosis is good, if the cause of
sinusitis is anatomically and is treated by surgery. More than 90% of patients
progressed to surgical intervention. However, these patients are likely to relapse,
so it takes regimens to prevent recurrence. In patients with acute bacterial sinusitis
with extension into the intracranial despite antibiotic therapy, the incidence of
morbidity and mortality is still high, of between 5% -10%. 13,15

Chapter 3
Conclussion
Sinusitis is an inflammation of the sinus lining caused by bacterial, viral and
/ or microbial nfections; as well as structural issues like blockages of the sinus
opening (ostium). If the sinus opening (ostium) is closed, normal mucus drainage
may not occur this condition may lead to infection and inflammation of the
sinuses.
Sinusitis is usually preceded by a cold, allergy attack or irritation from
environmental pollutants. Often, the resulting symptoms, such as nasal pressure,
nasal congestion, a runny nose, and fever, run their course in a few days.

35

However, if symptoms persist, a bacterial infection or acute sinusitis may develop.

If sinusitis occurs frequently or lasts three months or longer, it may be chronic
sinusitis.
The symptoms of acute sinusitis in adults very often follow a cold that does
not get better or that gets worse after 5 - 7 days. Symptoms include, bad breath or
loss of smell, cough, often worse at night, fatigue and general feeling of being ill,
fever,headache, pressure-like pain, pain behind the eyes, toothache, or tenderness
of the face, nasal stuffiness and discharge, sore throat and postnasal drip.
Symptoms of chronic sinusitis are the same as those of acute sinusitis. However,
the symptoms tend to be milder and last longer than 12 weeks.
Sinusitis is typically treated first with medication. Treatment with antibiotics
or topical nasal steroid sprays is often successful in reducing mucosal swelling,
fighting infection, and relieving obstructions of the sinus opening. Inhaling steam
or using nasal saline sprays or drops may also help relieve sinus discomfort.
However, at least 20% of patients do not respond adequately to medications
Most sinus infections can be cured with self-care measures and medical
treatment. If you are having repeated attacks, you should be checked for causes
such as nasal polyps or other problems, such as allergies.

36

References
1.
2.
3.
4.
5.
6.

7.

8.
9.
10.

11.
12.
13.

Watelet JB, Cauwenberge P Van. Applied anatomy and physiology of the

nose and paranasal sinuses. (1).
Ellis H. Clinical Anatomy. Main Street, Malden, Massachusetts; 2006.
Ameet Singh, MD; Chief Editor: Arlen D Meyers, MD M. Paranasal Sinus
Anatomy. http://emedicine.medscape.com/article/1899145-overview.
D A. Physiology of the nose and paranasal sinuses. Scott-Browns
Otorhinolaryngol Neck Surgery. 2008:1366-1369.
Flottes L, Clerc P RR et al. La physiologie des sinus. 1960;Libraire A.
Paulsson B, Dolata J, Ohlin P, Larsson I, Lindberg S. Paranasal sinus
ventilation in healthy subjects and in patients with sinus disease evaluated
with the 133-xenon washout technique. Ann Otol Rhinol Laryngol.
2001;110(7 I):667-674.
Lanza DC. Diagnosis of chronic rhinosinusitis. Ann Otol Rhinol Laryngol.
2004;113(5 II):10-14. http://www.embase.com/search/results?
subaction=viewrecord&from=export&id=L38623549\nhttp://sfx.unimi.it:9
003/unimi?sid=EMBASE
&issn=00034894&id=doi:&atitle=Diagnosis+of+chronic+rhinosinusitis&st
itle=Ann.+Otol.+Rhinol.+Laryngol.&title=Annals+of+Otology,+Rh.
Couch ME. Cummings Otolaryngology - Head and Neck Surgery.; 2010.
doi:10.1016/B978-0-323-05283-2.00009-4.
Mustafa M, Patawari P, Iftikhar HM, Shimmi SC, Hussain SS, Sien MM.
Acute and Chronic Rhinosinusitis , Pathophysiology and Treatment. Int J
Pharm Sci Invent ISSN. 2015;4(2):30-36.
Van Cauwenberge P, Watelet JB. Epidemiology of chronic rhinosinusitis.
Thorax. 2000;55(Suppl 2):S20-S21.
http://www.ncbi.nlm.nih.gov/pubmed/10992549\nhttp://www.pubmedcentr
al.nih.gov/articlerender.fcgi?artid=PMC1765976.
Choi S-H, Han M-Y, Ahn Y-M, et al. Predisposing Factors Associated With
Chronic and Recurrent Rhinosinusitis in Childhood. Allergy, Asthma
Immunol Res. 2012;4(2):80. doi:10.4168/aair.2012.4.2.80.
Lalwani AK. CURRENT Diagnosis & Treatment in OtolaryngologyHead
& Neck Surgery. 3 ed. (Companies TM-H, ed.). America: The McGrawHill Companies; 2012.
Fokkens WJ, Valerie JL, Joachim M, Claus B, Isam A, Fuad B, et al.
European Position Paper On Rhinosinusitis And Nasal Polyps 2012.
Rhinology 2012.

37

14.

Bailey BJ. acute rhinosisnusitis Bailey BJ. Head and Neck Surgery
Otolaryngology. Philadelphia, Lippincott Williams & Wilkins, 2014.
15.
Budiman
BJ,
Rosalinda
R.
Bedah
Sinus
EndoskopiFungsionalRevisipadaRinosinusitisKronis.
Diakses
dari:
http://tht.fk.unand.ac.id/makalah/83-bedah-sinus-endoskopi-fungsionalrevisi-pada-rinosinusitis-kronis.html.pada tanggal 4october 2016.
16. Mangunkusumo E, Soetjipto D. Sinusitis. Dalam Soepardi EA, et al, editor
.Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala dan Leher,
Ed 7. Jakarta, Balai Penerbit FK UI.2014.
17. Grevers G. Chapter 1: Anatomy, Physiology, and Immunology of Nose,
Paranasal Sinuses, and Face. Dalam: ProbstR,Grevers G, et al, editor.
Basic Otorhinolaryngology: A Step-By-Step Learning Guide. Germany
:Appl, Wemding; 2006. 4-7.
18. Hoang JK, James DE, Chistopher LT, Christine MG. Multiplanar Sinus CT
: A Systematic Approach to Imaging Before Functional Endoscopic Sinus
Surgery. ARJ 2010;194:527-36

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