Rhinogenic & Odontogenic

R h i n o s i n u s i t i s

Retno S. Wardani retno.wardani@ui.ac.id

Rhinology Consultant

ENT Department Faculty of Medicine University of Indonesia Jakarta

Rh in o s i n u s i t i s

1)Van Cauwenberge P, Van Kempen M, Bachert C. Mechanisms of Viral & Bacterial Infections of the

Nose & Sinuses; Pediatric Nasal & Sinus Disorders, 2005;199:59-67

2)Fireman P. Diagnosis of sinusitis in children: emphasis on the history and physical examination. J

Allergy Clin Immun, 1992;90:433-36

Rhinosinusitis = inflammatory disease

Bacterial Rhinosinusitis occur in following viral infection & allergic inflammation 1,2

How to control inflammation?

When to prescribe antibiotic?

RHINOSINUSITIS PATHOGENESIS

OMC

Mucocilliary

transport system

C l i n i ca l S ymptoms

2 ultimate symptoms

Nasal obstruction

Purulent nasal secretion

with / without

Facial pain

Anosmia / hyposmia

Nasal obstruction

Purulent nasal secretion

Facial fullness / pain

Anosmia / Hyposmia Fever in acute

Cough

Earache / ear fullness

Halithosis Dental pain

Headache

Fatigue

Fever in subacute / chonic

Fokkens et al, EPO3S, Rhinology

2007

Meltzer et al, Rhinosinusitis Developing

Guidance for Clinical Trial, JACI 2006

Rhinosinusitis Symptoms EP3OS Criteria Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang Supriyatno,

Damayanti R. Syarief, Clinical Symptoms & PNS Plain X-ray Compare to

Nasoendoscopy Examination As Diagnostic Criteria In Pediatric

Rhinosinusitis, Jakarta, 2009

Diagnostic Test For

Clinical Criteria of EP3OS

Sensitivity: 73% (95% CI 56% - 85%)

Specificity: 31% (95% CI 18% - 47%)

NASOENDOSCOPY EXAMINATION

Clinical

Criteria

EP3OS

Positive Negative Total

Positive 29 29 58

Negative 11 13 24

Total 40 42 82

Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang

Supriyatno, Damayanti R. Syarief, Clinical Symptoms & PNS Plain X-

ray Compare to Nasoendoscopy Examination As Diagnostic Criteria

In Pediatric Rhinosinusitis, Jakarta, 2009

Rhinosinusitis Symptoms (Modified) AAOHNS Criteria

Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang Supriyatno,

Damayanti R. Syarief, Clinical Symptoms & PNS Plain X-ray Compare to

Nasoendoscopy Examination As Diagnostic Criteria In Pediatric

Rhinosinusitis, Jakarta, 2009

Diagnostic Test For

Clinical Criteria of AAOHNS

Sensitivity: 80% (95% CI 64% - 91%)

Specificity: 14% (95% CI 5% - 28%)

NASOENDOSCOPY EXAMINATION

Clinical

Criteria

AAOHNS

Positive Negative Total

Positive 31 37 68

Negative 8 6 14

Total 39 43 82

Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang

Supriyatno, Damayanti R. Syarief, Clinical Symptoms & PNS Plain X-

ray Compare to Nasoendoscopy Examination As Diagnostic Criteria

In Pediatric Rhinosinusitis, Jakarta, 2009

Rhinosinusitis Spectrum

Based on Disease Duration

Acute Rhinosinusitis

Subacute Rhinosinusitis

Chronic Rhinosinusitis

30 days 90 days

Acute Recurrent Rhinosinusitis

3x in 6 months or 4x in 12 months

Free of symptoms between episodes

Acute Exacerbation on

Chronic Rhinosinusitis

Rhinosinusitis Classification

Rhinosinusitis

Acute: < 30 days

Subacute: 30 90 days

Chronic

Rhinosinusitis

Rhinosinusitis

Acute Recurrent

3x in 6 months 4 x in 12 months

Acute Exacerbation

on Chronic

Rhinosinusitis

NORMAL PHYSIOLOGIC PROCESS

PATHOLOGIC PROCESS

Radiologic Examination

PNS Plain x-ray is not recommended

diagnosis of acute uncomplicated RS should be

made on clinical grounds alone (EP30S 2007, American College of Radiology, 2000)

Plain x-ray technically difficult to perform

CT Scan recommended on:

Severe disease

Immunocompromised patients

Severe complications (orbital & intracranial)

For guiding surgical treatment

Radiologic

Appearance

ABRS (+) ABRS (-)

Frequency % Frequency %

Normal 3 18.8 13 81.2

Mucosal thickening 6 66.7 3 33.3

Opacification 5 71.4 2 28.6

Mucosal thickening +

opacification 9 47.4 10 52.6

Mucosal thickening +

air fluid level 1 100 0 0

Opacification +

air fluid level 2 100 0 0

All appearance 3 100 1 25

Radiologic Appearance of Plain Sinus X-ray

in Pediatric Acute Rhinosinusitis

Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang Supriyatno, Damayanti R.

Syarief, Clinical Symptoms & PNS Plain X-ray Compare to Nasoendoscopy

Examination As Diagnostic Criteria In Pediatric Rhinosinusitis, Jakarta, 2009

Diagnostic Test For Plain X-Ray

Paranasal Sinus

Sensitivity: 87% (95% CI 73% - 96%)

Specificity: 47% (95% CI 31% - 62%)

NASOENDOSCOPY EXAMINATION

Plain X

Ray

Paranasal

Sinus

Positive Negative Total

Positive 34 23 57

Negative 6 19 25

Total 40 42 82

Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang

Supriyatno, Damayanti R. Syarief, Clinical Symptoms & PNS Plain X-

ray Compare to Nasoendoscopy Examination As Diagnostic Criteria

In Pediatric Rhinosinusitis, Jakarta, 2009

Radiologic

Appearance

Sensitivity Specificity

% 95%CI % 95%CI

Mucosal thickening 64 47 - 79 58 42 - 73

Opacification 67 50 - 81 56 40 - 71

Air-fluid level 18 8 - 34 95 84 - 99

Mucosal thickening +

opacification 44 28 -60 67 52 - 81

Mucosal thickening + air fluid

level 13 4 - 27 95 84 - 99

Opacification + air fluid level 15 6 - 31 98 88 99

Radiologic Appearance of

Pediatric Acute Rhinosinusitis

Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang Supriyatno, Damayanti R.

Syarief, Clinical Symptoms & PNS Plain X-ray Compare to Nasoendoscopy

Examination As Diagnostic Criteria In Pediatric Rhinosinusitis, Jakarta, 2009

Rhinogenic Maxillary Sinusitis caused by Septal Deviation & Concha Bullosa

Odontogenic Maxillary Sinusitis

Odontogenic Maxillary Sinusitis

How To control

inflammation

&

when to PRESCRIBE

antibiotic

Correlation Between Antimicrobial

Use & Bacterial Resistance

ANTIBIOTICS

R Setiabudy, WHD April 7, 2011

20

We have reached a CRUCIAL TIME:

Rise of antibiotic resistance

A steady decline in the rate of

discovery of new antibiotics

CONCEPTUALLY NOVEL THERAPEUTIC

STRATEGIES AGAINST MICROBIAL INFECTION

Prevention of Antibiotic Resistance

Antibiotic Prescribtion Indication

Rhinosinusitis & Asthma Bronchitis

Eustachia

n Tube

Ostiomeatal

Complex

(OMC)

Nasopharynx -

Adenoid

Antibiotic Prescribtion Indication

Rhinosinusitis & Otitis Media

Adenoid Hypertrophy

RINOSINUSITIS OTITIS MEDIA

Ventilation & Drainage

Disturbance

OMC Eustachian

Tube

David S. Parsons

Parsons DS, Wald ER. Otitis media and sinusitis: similar disease.

Otolaryngol Clin North Am, 1996;29:11-25

Antibiotic for Bacterial Infection Only

Microbiological Result Frequency

No growth 9 (20,9%)

Suprohaita, Wardani RS, Munasir Z, Supriyatno B, Syarief DR, Clinical

Symptoms & PNS Plain X-ray Compare to Nasoendoscopy Examination As

Diagnostic Criteria In Pediatric Rhinosinusitis, 2009

Purulent secretion should not be used to assess the need for antibiotic therapy discoloration & thickening is related to

presence of neutrophils, not bacteria.

S E V E R E S Y M P TO M S for at least 3-4 consecutive days at the initial time

Fever at least 390 C Purulent nasal discharge

Antibiotic Prescribtion Indication

DO NOT TARGET THE PATHOGEN DIRECTLY

enhance immunomodulatory molecules / host defence mechanism

to eliminate the pathogen

Efficient mucocilliary

clearance

DO NOT TARGET THE PATHOGEN DIRECTLY

enhance immunomodulatory molecules / host defence mechanism

to eliminate the pathogen

Mookherjee, Hancock, Cationic host defence peptides: Innate immune regulatory peptides as a novel approach for treating

infections Cell. Mol. Life Sci. 64 (2007) 922 933

Maxillary Sinus Puncture

Maxillary Sinus Puncture

Maxillary Sinus Puncture

Orbital Complication of Rhinosinusitis

Orbital Abscess of

Odontogenic Origin

1. the maxillary premolar and molar teeth

the maxillary buccal plate posteriorly into the pterygopalatine & infratemporal fossae the orbit through inferior orbital fissure

the posterior maxillary wall to enter the maxillary sinus

2. through the valveless anterior facial, angular & ophthalmic veins

Yousef, OH. Odontogenic Orbital Cellulitis,

Ophthalmic Plastic and Reconstructive Surgery

2008(24);1: 2935

Odontogenic Orbital Cellulitis

ESS FOR ORBITAL ABSCESS

Courtesy of Dr. Damayanti Soetjipto

TERIMA KASIH

Sinus Pathology in

Common Pediatric Airway Disease

Subjects 82 children > 6years, 44 boys, 38 girls

History, Physical

Examination & Plain X ray

Allergic Rhinitis: 54/82 (65.9%) Chronic Recurrent Cough: 37 /82 (45.1%) Asthma: 33/82 (40,2%) URTI: 3/82 (3,7%)

Nasoendoscopy Examination & BACTERIAL CULTURE

Acute Bacterial Rhinosinusitis: 40/82 (48.8%)

Suprohaita, Retno S. Wardani, Zakiudin Munasir, Bambang Supriyatno, Damayanti R.

Syarief, Clinical Symptoms & PNS Plain X-ray Compare to Nasoendoscopy

Examination As Diagnostic Criteria In Pediatric Rhinosinusitis, Jakarta, 2009

Microbiological Result of

Pediatric Acute Bacterial Rhinosinusitis

Microbiological Result Frequency

No growth 9 (20,9%)

Staphylococcus aureus 18 (41,86%)

Streptococcus pneumoniae 14 (32,6%)

Streptococcus pyogenes 1 (2,3%)

Pseudomonas aeruginosa 1 (2,3%)

Suprohaita, Wardani RS, Munasir Z, Supriyatno B, Syarief DR, Clinical

Symptoms & PNS Plain X-ray Compare to Nasoendoscopy Examination As

Diagnostic Criteria In Pediatric Rhinosinusitis, 2009

symptomatology

pathophysiology

pathology

adaptive response

insults

pathogenesis

Diagnosis & Treatment of ENT Disease

(organ related symptoms)

Diadaptasi dari: from wheeze to sneeze, dr. Darmawan, SpA

headache

maxillary sinusitis

Rhinogenic & Odontogenic Origin

Maxillary Sinusitis

Anatomical Variation Obstructing OMC

Septal Deviation

Concha Bulosa

Lateral Deflection of Uncinate Process