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12/04/2011

Nama Tempat/tgl lahir : Dr. Cita Herawati Murjantyo, Sp THT-KL : Yogyakarta, 15 Maret Pekerjaan/jabatan
Nama
Tempat/tgl lahir
: Dr. Cita Herawati Murjantyo, Sp THT-KL
: Yogyakarta, 15 Maret
Pekerjaan/jabatan :
Staf Medik Fungsional RS Kanker Dharmais
Bagian THT – RSI Bintaro
Riwayat Pendidikan Formal
Spesialis THT, FKUI/RSCM-1998
Sedang pendidikan S3, Universitas Gajahmada Yogyakarta
Riwayat Pendidikan Tambahan
Endoscopic & Skull Base Surgery, Masterclass, Milano 2003
OSAS Obstructive Sleep Apnea Syndrome/SNORING, Singapore
General Hospital, 2006
Head & Neck Course, Singapore General Hospital,2007
European Allergic Course, Greece, 2008
Cita Herawati RS Premier Bintaro PERANAN AUGMENTIN PADA TERAPI RHINOSINUSITIS
Cita Herawati
RS Premier Bintaro
PERANAN AUGMENTIN PADA
TERAPI RHINOSINUSITIS

12/04/2011

Anatomy of the sinus

Anatomy of the sinus Osteomeatal Complex
Anatomy of the sinus Osteomeatal Complex

Osteomeatal Complex

United Airway Disease

Integrated Airway System

Same histologic & physiologic organ

Same pathology mechanism

Same analogy & hypothesis careful analysis &

interpretation

organ  Same pathology mechanism  Same analogy & hypothesis  careful analysis & interpretation

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Rhinosinusitis Definition

AAO definition-

Defined as an inflammation of the nose and sinuses

Rhinosinusitis

Include nasal airway inflammation (Rhinitis)

as an inflammation of the nose and sinuses  Rhinosinusitis  Include nasal airway inflammation (Rhinitis)

Rhinosinusitis Symptoms

A rhinosinusitis task force in 1997

"major" criteria

facial pain

nasal obstruction

Hyposmia

purulence on examination

fever

"minor" criteria

Headache

Fatigue

dental pain

cough

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-- Viral Infection  Self Limiting Disease Unless There Is Secondary Bacterial Infection
--
Viral Infection
 Self Limiting Disease
Unless There Is Secondary Bacterial
Infection

Viral infections

Most common predisposing factors for sinusitis in children

Day care important risk

Reduce viral exposure among children

Prevention

Hand washing

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Distinguishing ABRS from ARS caused by viral upper respiratory infection Term Definition Acute rhinosinusitis Up
Distinguishing ABRS from ARS caused by
viral upper respiratory infection
Term
Definition
Acute
rhinosinusitis
Up to 4 weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal
obstruction, facial pain-pressure-fullness, or both:
• Purulent nasal discharge is cloudy or colored, in contrast to the clear secretions that
typically accompany viral upper respiratory infection, and may be reported by the
patient or observed on physical examination
• Nasal obstruction may be reported by the patient as nasal obstruction,
congestion, blockage, or stuffiness, or may be diagnosed by physical examination
• Facial pain-pressure-fullness may involve the anterior face, periorbital region, or
manifest with headache that is localized or diffuse
Viral rhinosinusitis
(VRS)
Acute rhinosinusitis that is caused by, or is presumed to be caused by, viral
infection. A clinician should diagnose VRS when:
a. symptoms or signs of acute rhinosinusitis are present less than 10 days and the
symptoms are not worsening
Acute bacterial
rhinosinusitis
Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterial
infection. A clinician should diagnose ABRS when:
(ABRS)
a. symptoms or signs of acute rhinosinusitis are present 10 days or more beyond
the onset of upper respiratory symptoms, or
b. symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial
improvement (double worsening)
(Adapted from ref 1)
9
1. Rosenfeld RM, Andes D, Bhattacharyya N et al. Clinical practice guideline : Adult sinusitis. Otolaryngology Head & Neck Surgery; 2007; 137:S1-S31.

Classification by Duration of

Symptoms

ACUTE lasting up to 4 weeks, with total resolution of symptoms

SUBACUTE persisting more than 4 weeks, but less than 12 weeks, with total resolution of symptoms

CHRONIC 12 weeks or more of signs / symptoms

RECURRENT ACUTE 4 or more episodes per year, with resolution of symptoms between attacks

12/04/2011

2007 AAcutecute BacterialBacterial RhinosinusitisRhinosinusitis GejalaGejala meningkatmeningkat >> 55 harihari
2007
AAcutecute BacterialBacterial RhinosinusitisRhinosinusitis
GejalaGejala meningkatmeningkat >> 55 harihari
GejalaGejala menetapmenetap >> 1010 harihari
CommonCommon
ColdCold
AcuteAcute ViralViral
RhinosinusitisRhinosinusitis
00
55
1010
1515
1212
HariHari
MingguMinggu
FokkensFokkens W,W, LundLund V,V, MullolMullol J,J, etet al.al. RhinologyRhinology 20072007 (Suppl(Suppl 20):20): 11 -- 136.136.
web:web: www.rhinologyjounal.comwww.rhinologyjounal.com //
www.ep3os.orgwww.ep3os.org
SymptomsSymptoms
Rhinosinusitis Spectrum Based on Disease Duration 4 weeks 12 weeks Acute Subacute Chronic Rhinosinusitis
Rhinosinusitis Spectrum
Based on Disease Duration
4 weeks
12 weeks
Acute
Subacute
Chronic
Rhinosinusitis
Rhinosinusitis
Rhinosinusitis
Acute Recurrent Rhinosinusitis
3x in 6 months or 4x in 12 months
Free of symptoms between episodes

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2007 AcuteAcute RhinosinusitisRhinosinusitis TreatmentTreatment SymptomaticSymptomatic TreatmentTreatment ++
2007
AcuteAcute RhinosinusitisRhinosinusitis TreatmentTreatment
SymptomaticSymptomatic TreatmentTreatment
++ CorticosteroidCorticosteroid intranasalintranasal
±± oraloral antibioticantibiotic
CommonCommon ColdCold
AcuteAcuteViralViral RhinosinusisitisRhinosinusisitis
AcuteAcute RhinosinusitisRhinosinusitis
00
HariHari
55
1010
1515
IntensitySymptoms
Symptoms Intensity

Pathogenesis of ABRS changes from acute to chronic

In acute maxillary sinusitis S pneumoniae, H influenzae, and M catarrhalis predominate

In chronic maxillary sinusitis anaerobic bacteria are the main isolates

Peptostreptococcus, Fusobacterium, and pigmented Prevotella and Porphyromonas

β-Lactamase–producing bacteria were isolated in 46% of the patients

Brook I. Bacteriology of Acute and Chronic Frontal Sinusitis. Arch Otolaryngol Head Neck Surg. 2002;128:583-58.

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Chronic rhinosinusitis (CRS)

Symptom-based diagnosis may be unreliable

Patient with “sinus all the time,” chronic headache and facial “pressure,” plus “stopped up” nose; has had “innumerable” courses of antibiotics and 3 sinus operations by 2 different physicians

Computed tomography is the gold standard

courses of antibiotics and 3 sinus operations by 2 different physicians  Computed tomography is the

Predisposing Factors In Chronic rhinosinusitis (CRS)

Host Factors

Systemic

Allergic rhinitis

Immunodeficiency

IgG subclasses

IgA

Genetic/congenital

cystic fibrosis, ciliary dyskinesia

Local

Anatomic obstruction

Gastroesophageal reflux

Enviromental factors

Microorganisms

viral illness (children in

daycare)

Pollutants

cigarette smoke

Medications

Rhinitis

medicamentosa

12/04/2011

Possible Strategies for Treating CRS Treat Treat Infectious Etiology Etiology –– AllergenAllergen
Possible Strategies for
Treating CRS
Treat
Treat
Infectious
Etiology
Etiology
–– AllergenAllergen AvoidanceAvoidance
–– AllergenAllergen AvoidanceAvoidance
Anatomic
– –
Antibiotics
Antibiotics
Allergy
– –
Surgery
Surgery
Attenuate
Attenuate
Inflammation
Inflammation
IL-5, IL-4
IL-5, IL-4
– –
Steroids
Steroids
IL-8, IF-
IL-8, IF-
– –
Immunotherapy
Immunotherapy
GM-CSF
GM-CSF
– –
Antileukotrienes
Antileukotrienes
– –
Macrolides
Macrolides
CRSCRS
– –
Who knows what else?
Who knows what else?

Antibiotics in CRS

Should be based on culture results

Endoscopic directed culture of purulent secretions from the nasal vestibule or middle meatus correlate well with maxillary tap results

S. aureus, Anaerobes & Gram negative

PseudomonaAeruginosa

12/04/2011

Antibiotics

First-line

 amoxicillinamoxicillin--clavulanateclavulanate

cephalosporin second-or third-generation

Second-line

For adults

The respiratory quinolones

ciprofloxin, levofloxacin, gatifloxacin, and moxifloxacin

 For adults  The respiratory quinolones  ciprofloxin, levofloxacin, gatifloxacin, and moxifloxacin 10

12/04/2011

Augmentin TM - Reliable efficacy in ABRS

The Sinus and Allergy Health Partnership (SAHP) guidelines 7

Recommend any of the following as initial therapy in adults with mild disease who have not received antibiotics in the previous 4 to 6 weeks: amoxicillin-clavulanate, amoxicillin, cefpodoxime proxetil, cefuroxime axetil or cefdinir

Several guidelines include amoxicillin- clavulanate as a first- line/second-line treatment option (France, Germany, USA, Spain, UK, Belgium, Netherlands, Finland, Canada)

8

Poole MD, Portugal LG. Treatment of rhinosinusitis in the outpatient setting. Am J Med 2005;118 (7A):45S–50S.

Klossek JM, Federspil P. Update on treatment guidelines for acute bacterial sinusitis. Int J Clin Pract 2005; 59 (2): 230–238

21

Conclusion

CRS is multifactorial

Treatment is based on patient’s predisposing factors

Therapeutic options

on patient’s predisposing factors  Therapeutic options  Prevent & treat etiology  Reduce inflammatory

Prevent & treat etiology

Reduce inflammatory response

Surgery

Exhaustion of medical option

Certainty of diagnosis

12/04/2011

Thank you

9 April 2011