ACUTE ETMOIDITIS

Definisi

Ethmoiditis adalah infeksi dari sinus-sinus

ethmoid, yang berbentuk sepertisarang
lebah terdiri dari sel-sel udara yang
berkumpul antara kavum nasal dan orbita
Akut ethmoiditis biasanya timbul dari
penyebaran infeksi dari sinus-sinuslain.
Ethmoiditis merupakan kasus yang jarang
dan dapat terjadi pada semua umur

Etiologi

Ethmoiditis sering merupakan komplikasi dari

infeksi saluran nafas atasseperti influenza
Gangguan drainase karena sumbatan ostium
dapat juga menjadipenyebabnya seperti polip,
benda asing, abnormalitas anatomi (seperti
septumdeviasi), tumor, imunokopromise,
trauma, gangguan letak saluran GIT,
danabnormalitas dari motilitas silia mukosa
Infeksi pada gigi juga dapat merupakan fokal
infeksidan menyebar terutama melalui
pembuluh darah

faktor resiko untuk terjadinya

ethmoiditis

Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Streptococcus pyogenes

Ethmoiditis

Signs & symptoms

Pain localized over the bridge of the

nose, medial and deep to the eye
Oedema of the lip both eyelids become
puffy and swollen
Nasal discharge on anterior rhinoscopy,
pus may seen in the middle and superior
meatus depending on the involvement of
anterior or posterior groups of ethmoid
sinuses
Swelling of the middle turbinate

Healthy sinuses vs
inflammation sinuses

Treatment

Treatment

= maxillary sinusitis
Visual disturbance and exophtalmus
abscess in the posterior orbit

Drainage of the ethmoid sinuses into the

nose
External ethmoidectomy
Fess

Complication

Fungal sinusitis

Fungi are eukaryotic organisms

comprising of moulds, yeasts,
mushrooms and other similar
organisms. Among this group of
organisms only about 0.1% are
human pathogens. The term
mycosis isused to define diseases
caused by fungi.

Epidemiology

Fungal infections of nose and sinuses

are getting common these days. With
increasing incidence of HIV and other
diseases like diabetes which compromise
host immunity it is no wonder thatthe
incidence of fungal infections involving
nose and para nasal sinuses is on the
rise.In India the incidence of fungal
sinusitis in immuno competent patients
is also showing a rise. This particular
fact need to be studied f

Classification

Acute fulminant invasive sinusitis

Chronic invasive fungal sinusitis
Granulomatous invasive fungal
sinusitis
Fungal ball
Allergic fungal rhino sinusitis

Acute fulminant invasive sinusitis: The

whole duration of illness in these
patients is just less than 4 weeks. These
patients are mostly immunocompromised
individuals.The reduced immunitycould
very well be a result of
a.Diabetes mellitus
b. AIDS
c. Immunosuppressive medicines
d. Malignancy causing immune
suppression

The fungus commonly associated with

this infectionbelongs to Mucoraceae
family or Aspergillus family. If Mucor is
involved then the lesion is
angioinvasive and destroys both bone
and soft tissue. Patients belonging to
this group have high mortality rate.
Extensive surgical debridement of the
lesion with removal of necrotic tissue
should be performed and must be
followed with intravenous antifungal
medication i.e. amphotericin B

Chronic invasive fungal sinusitis: This

condition is also known as Non
granulomatous chronic invasive fungal
sinusitis. This condition commonly afflicts
patients with diabetis mellitus. This disorder
is characterised by low grade inflammation
with tissue necrosis. There is very little
vascular invasion.
Granuloma formation which is common in
these patients requires an appropriate cell
mediated immune response which is common
in diabetics.
The duration of this disease is longer than 4
weeks (more than 6 weeks in somecases).
Orbital extension is common, causing
proptosis. These patients can be managed
by wide surgical debridement, followed by
systemic intravenous antifungal drugs like
amphotericin B.

Granulomatous invasive fungal sinusitis:

This condition is also known asIndolent
fungal sinusitis. These patients have an
intact cell mediated immune reponse.
Clincially it is virtually impossible to
distinguish it from non granulomatous
fungal sinusitis. Histopathology will clinch
the diagnosis. The intact immune system of
the patient limits the invasion to the
superficial mucosa. Granulomas could be
seen surrounding the fungal elements thus
preventing their deeper invasion. The
granulomas could be seen surrounded by
multinulceated giant cells, eosinophils etc.
Surgical debridement alone is sufficient to
cure these patients.Their intact immune
system takes over from now on.

Fungal Ball: These mycetomas commonly

present as unilateral opacificationof
maxillary or sphenoid sinus. The ethmoids
and frontal sinuses are very rarely
involved. These patients are usually
immunocompetent without evidence of
atopy. The fungal ball is composed of
tightly packed hyphae often from
Aspergillus, Alternaria and P. boydii.
Treatment is mostly surgical removal of
the fungal masscombined with
widenening of ostium there by increasing
the ventilation ofthe sinuses. Antifungal
drugs are not indicated in these patients.

Allergic fungal sinusitis: These

patients have a combination of nasal
polyposis, crust formation associated
with positive sinus cultures for
aspergillus. Robson (1989)introduced
the term allergic fungal sinusitis to
describe the findings associated with
this disease. These patients
consistently demonstrate allergic
reactions to aspergillus proteins

Bent's criteria for the diagnosis of

allergic fungal sinusitis:
1.Demonstrable type I
hypersensitivity to fungi
2. Nasal polyposis
3. Radiological findings (Heterodense
mass lesion)
4. Presence of eosinophilic mucin
mixed with noninvasive fungus
5. Positive fungal stain / fungal culture