CASE REPORT

ACUTE RHINOSINUSITIS IN ADULT

Moderator : dr Donny
Presentator :
Group A.11.2

Department of Otorhinolaryngology-Head and Neck Surgery

Medical Faculty Gadjah Mada University/dr. Sardjito Hospital
Yogyakarta
2012

CHAPTER I
INTRODUCTION
Introduction
The term rhinosinusitis is used interchangeably with sinusitis. This is because the
nasal mucosa is contiguous with that of the paranasal sinuses, any inammation of the
sinuses is almost always accompanied by inammation of the nasal cavity (Meltzer E. O. et.
al, 2004). Rhinosinusitis is an extremely common condition. In a national health survey
conducted during 2008, nearly 1 in 7 (13.4%) of all noninstitutionalized adults aged 18
years were diagnosed with rhinosinusitis within the previous 12 months (Pleis J. R. et. al,
2009). Incidence rates among adults are higher for women than men (~1.9-fold), and adults
between 45 and 74 years are most commonly affected (Pleis J. R. et. al, 2009).
Acute rhinosinusitis is dened as an inammation of the mucosal lining of the nasal
passage and paranasal sinuses lasting up to 4 weeks. It can be caused by various inciting
factors including allergens, environmental irritants, and infection by viruses, bacteria, or
fungi. A viral etiology associated with a URI (upper respiratory tract infection) or the
common cold is the most frequent cause of acute rhinosinusitis. Prospective longitudinal
studies performed in young children (635 months of age) revealed that viral URI occurs
with an incidence of 6 episodes per patient-year (Revai K. et. al, 2007). In adults, the
incidence is estimated to be 23 episodes per year (Fokkens W. et. al, 2007).
Secondary bacterial infection of the paranasal sinuses following an antecedent viral
URI is relatively uncommon, estimated to be 0.5%2% of adult cases (Gwaltney J. M. et. al,
2004) and approximately 5% in children (Wald E. R. et. al, 1991). The prevalence of a
bacterial infection during acute rhinosinusitis is estimated to be 2%10%, whereas viral
causes account for 90%98% (Gwaltney J. M. et. al, 2004). The total direct healthcare costs
attributed to a primary medical diagnosis of sinusitis in 1996 were estimated to exceed $3
billion per year (Ray N. F. et. al, 1999).
The maxillary sinus is an inflammatory and/or infectious process originating by
bacterial, fungal, or viral infection developed in the maxillary sinus. It can be presented in
isolation or associated with processes that affect one or more adjacent sinuses (Guiliand &
Laurent, 2005). The maxillary sinus belonging to the nasal and oral cavity is the most
susceptible of the all sinus to the invasion by pathogenic bacteria, either through their
communication with the nasal cavity, or the product of odontogenic infection established
their home via nasal (rinogenic), allergic, or tooth route (Brook, 2006).
2

Of the total cases of maxillary sinusitis, approximately 1012% is exclusively

sinusitis of the home tooth (Brook, 2006; Costa et al. 2007). The close relationship between
the roots of the maxillary posterior teeth and the floor of the sinus makes the infection in
these pieces directly affect the integrity sinus. It has been shown that the closer the apex of a
tooth to the floor of the maxillary sinus, greater is the impact on the antral tissues (Selden,
1999), this being the most important cause of the infections of periapical and periodontal
origin (Cohen & Rockaway, 1957), along with accidents in the process of extraction of teeth
(Uckan & Buchbinder, 2003).

BAB II
Definition
Rhinosinusitis is an inflammatory process involving the mucosa of the nose and one
or more sinuses. The mucosa of the nose and the sinuses form a continuum and thus more
often than not the mucous membranes of the sinuses are involved in diseases which are
primarily caused by an inflammation of the nasal mucosa. Acute viral rhinosinusitis often
referred to as common cold is the commonest viral infection in man and the commonest
inflammatory. For epidemiological studies the definition is based on symptomatology without
ENT examination or radiology.
Acute rhinosinusitis (ARS) is defined as:
Sudden onset of 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;for <12 weeks; with symptom free intervals if the problem is
recurrent; with validation by telephone or interview.
Questions on allergic symptoms i.e. sneezing, watery rhinorrhea, nasal itching and itchy
watery eyes should be included.
Acute rhinosinusistis can occur once or more than once in a defined time period. This is
usually expressed as episodes/year but there must be complete resolution of symptoms
between episodes for it to constitute genuine recurrent acute rhinosinusitis.

Common cold/ acute viral rhinosinusitis is defined as: duration of symptoms for less than 10

days.
Acute non-viral rhinosinusitis is defined as: increase of symptoms after 5 days or persistent
symptoms after 10 days with less than 12 weeks duration.
Incidence
The incidence of acute viral rhinosinusitis (common cold) is very high. It has been
estimated that adults suffer 2 to 5 colds per year, and school children may suffer 7 to 10 colds
per year. The exact incidence is difficult to measure because most patients with common cold
do not consult a doctor. Recently a case control study in the Dutch population concluded that
an estimated 900,000 consultations take place annually for acute respiratory tract infection.
Rhinovirus (24%) and Influenzae (11%) were the most common agents isolated.
4

An average of 8.4 % of the Dutch population reported at least one episode of ARS per year in
1999 The incidence of visits to the general practitioner for acute sinusitis in the Netherlands
in 2000 was 20 per 1,000 men and 33.8 per 1,000 women (44). According to National
Ambulatory Medical Care Survey (NAMCS) data in the USA, sinusitis is the fifth most
common diagnosis for which an antibiotic is prescribed.
Sinusitis have been medical problem almost in all countries and the number of prevalence is
increasing each year. Sinusitis can be found easily and included in the top ten the most
expensive disease because it need high cost treatment. Most of rhinosinusitis patient is
woman. The prevalence of sinusitis in Indonesia is high. From the research at 1996 in
Department Rhinology FKUI RSCM, from 496 ambulatory patients, it is found that 50% was
chronic sinusitis patient. In 1999, the research which was held in Department of
Otolaryngology in FKUI RSCM with Pediatrician, it found that the prevalence of acute
sinusitis in Upper Respiratory Tract Infection patients is 25%.
Anatomy and Physiology
General structure:

Skeleton:
Bony (osseous) frame: radix & dorsum nasi
Cartilagenous frame: apex & alae nasi (nostril)

Vessels:
Arteries: branches from a.ophthalmica, a.maxillaris, a.facialis
Veins: drain to v.facialis & v.ophthalmica

Nerves
Motoric: r.buccalis n.facialis
Sensory: branches from n.ophthalmicus & n.maxillaris

External Nose
1. Bridge
2. Dorsum Nasi
3. Tip
4. Ala Nasi
5. Columella
6. Nares Anterior

The Skleleton : 1).Nasal bone, 2).proc. Frontalis os Maxila, 3).proc Nasalis os. Frontalis
The Cartilages : 1) Paired superior lateral nasal cartilage, 2). Paired inferior lateral nasal
cartilages (ala major), 3). Anterior part of septal cartilage
Septum
Bone part
1. Perpeducularis plate of Ethmoid
2. Vomer
3. Nasal crest of Maxilla
4. Nasal crest of Palatina
Cartilage part
1). Septal cartilage (quadrangular plate)
2). Kolumella
LATERAL WALL
1. Conchae Inferior
2. Conchae Media
3. Conchae Superior

Part of Ethmoid Labirynth

4. Conchae Suprema (rudimenter)

The nasal conchae act to:
increase the surface area exposed to the air
make the airflow turbulent, which makes it slow down.
These factors increase our ability to filter the inspired air.

The nasal cavity is surrounded by a ring of paranasal sinuses located in the frontal,
sphenoid, ethmoid, and maxillary bones.

Paranasal sinuses probably act to :

Humidifying and warming inspired air

Regulation of intranasal presure

Increasing surface area for olfaction

Lightening the skull

Resonance

Absorbing shock

Contribute to facial growth

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Osteomeatal complex:
- Ostium: opening within the maxillary sinus
- Infundibulum: the canal like struture
- Hiatus semilunaris: slit like air space, situated superior to uncinate process, anteroinferior to
bulla ethmoidalis
- Uncinate process: sickle shaped bone extension of the medial wall, rarely pneumatized
- Bulla ethmoidalis: largest ethmoidal bulla, situated anteroinferiorly
- Middle meatus: where hiatus semilunaris opens
Nasal Cavity
General Functions:

To warm, moisten, and filter

the incoming air

To receive olfactory stimuli

To provide resonating chambers for

speech sounds

Vascularization
branches from a.ophthalmica: r.ethmoidalis ant & post.
branches from a. maxillaris interna: r.sphenopalatinus, palatina major
Veins accompany arteries & form a rich network beneath the mucous
membrane
Opthalmic vein doesnt have the valves Sinus Cavernosus = predisposition factor of
intraranial infection
Innervation
Ordinary sensations
n. Opthalmica (V1) n. nasociliaris n. Ethmoidalis Ant.
Gang. Sphenopalatine n. maxillaris (V2)
Olfactory nerves
Autonomic nerves
Parasympathetic : n. Petrossus superficialis

Sympathetic : n. Petrossus profundus

Mucociliary Clearance

Respiratory: ciliated pseudostratified columner epitherlim

In normal condition the respiratory mucous is pinkish and always wet. Because its surface
is covered by mucous blanket. Beneath the epitel, there are tunica propria which contain
much blodd vessels, mucous glands, and lymphoids.
The arteries beneath the mucous of nasal cavity have an unique structure. The arterioles
give blood supply for the capillary plexus which then the efferent vessels of this plexus will
open to the large venous sinusoidal space. These sinusoids have sphincter muscles to flow the
blood to the inner venous plexus then to the venula. Theese structures have similarity with
erectile cavernous tissues. Finally, vasodilatation and vasoconstriction are controlled by
otonomic nerves.

Olfactory mucous: pseudostratified collumner non ciliated

Located on the roof of nasal cavity, superior conchae, and superior one-third of the
septum. These epitel consist of three kind of cells : suspensorium, basal, and olfactory
receptor cell. The mucous area is yellowish brown.
Mucocilliary Transport
Mucocilliary transport is the active defense mechanism of the nasal cavity against virus,
bacterial, fungal, or dangerous particle inhaled together with the air. The efectivity of
mucocilliary transport is influenced by the quality of cilia and mucous blanket (produce by
goblet cells).
Inner part of mucous blanket consist of serous fluid which contains lactoferin, lisozyme,
leucoprotease secterory inhibitor, and secretory IgA (s-IgA). While its surface consists of
more elastic mucous which contains much plasma protein such as albumin, IgG, IgM, and
complement factor.

Patophysiology

The pathophysiology of ARS remains underexplored because of the difficulty of obtaining

mucosal samples during the course of the disease. Few experimental models have been
dedicated to bacterial infections though experimental models of viral rhinosinusitis in animals
and man exist.The common cold is commonly presumed to be implicated in opportunistic
bacterial infections due to impairment of mechanical, humoral and cellular defences and
epithelial damage. Usually two phases of reaction are described: a non-specific phase where
the mucus and its contents (eg: lysozyme, defensin) play a major role and a second including
the immune response and inflammatory reaction. Common cold symptoms are usually shortlived with a peak of severity at 48 hours; the course of bacterial infection appears longer.
Some previous studies have confirmed preferential association and cooperation between virus
and bacteria eg, Influenzae A virus and streptococcal infection, HRV-14 and S.pneumoniae.
The mechanism of this superinfection may be in relation to viral replication which increases
bacterial adhesion. However rhinovirus, the most frequent cause of the common cold is not
associated with major epithelial destruction nor immunosuppression. An initial mechanism
involving release of IL-6 and IL-8 and overexpression of ICAM may be relevant.
Histopathology: inflammatory cells and mediators
From single case reports or a single study including 10 patients with complications,
neutrophils are mainly found in the mucosa and the sinus fluid. Epithelial cells are the first
barrier in contact with virus or bacteria. These release and express several mediators and
receptors to initiate different viral elimination mechanisms Recently evidence of biofilms has
been suggested in experimentally-induced bacterial (pseudomonas) sinusitis in rabbits.
1. Epithelial cells
No specific studies are available concerning the role of epithelial cells in ARS. In cases of
experimental induced viral rhinosinusitis, epithelial damage is observed. In vitro release of Il6 after rhinovirus innoculation has been found. Epithelial cells in contact with human
rhinovirus express intracellular adhesion molecule 1 (ICAM-1) which belongs to the
immunoglobulin supergene family. Membranous (m-ICAM) and circulating (s-ICAM) forms
are detected during common colds and expressed in vitro by epithelial cells.
2. Granulocytes

Neutrophils are responsible for proteolytic degradation due to the action of protease. In vitro
leucocytes produce lactic acid during S. pneumoniae induced rhinosinusitis.Neutrophils are a
likely source of IL-8 and TNF-.
3. T lymphocytes
These are stimulated during ARS by pro-inflammatory cytokines such as IL-1, IL-6 and
TNF-. Experimentally, antigen stimulated TH2 seems active in the augmented response to
bacterial with S. pneumoniae in allergic mice.
4. Cytokines
Mucosal tissue sampled from the maxillary sinus in ARS (n=10), demonstrated significantly
elevated IL-8 concentrations compared to 7 controls. IL-8 belongs to the CXCchemokine
group and is a potent neutrophil chemotactic protein, which is constantly synthesized in the
nasal mucosa. Similar results, though not reaching significance, were obtained for IL-1 and
IL-6, whereas other cytokines such asGM-CSF, IL-5 and IL-4 were not upregulated.
Another study confirm that some specific cytokines were more implicated inARS (IL-12, IL4, IL-10, IL-13). Recently, IL-8, TNF-alpha and total protein content were increased in nasal
lavage from subjects with ARS compared to controls and allergic rhinitis subjects. The
cytokine pattern found in ARS resembles that in lavage from naturally acquired viral rhinitis.
5. Adhesion molecules
Human rhinoviruses use intercellular adhesion molecule-1 (ICAM-1) as their cellular
receptor. Expression of cell adhesion molecules are induced by pro-inflammatory cytokines.
6. Neuromediators
The role of the nervous system in ARS is not documented but probably needs further
investigation. Human axon responses are considered as an immediate protective mucosal
defense mechanism but no specific investigation has been performed during ARS.
Odontogenic sinusitis
It is one of the most important causes of chronic sinusitis. The base of the maxillary
sinus is the alveolar process of the teeth root canal at the upper jaw. This means the maxillary
sinus space is only separated from the root canal by a thin layer of bone, or in some there is
10

even no such layer of bone. Infection of the teeth in the upper jaw such as in the infection of
the apical teeth root canal or the inflammation of the periodontal tissue can easily spread
directly to the sinus, or through blood vessels and lymph.
Odontogenic sinusitis is a well-recognized condition and accounts for approximately
10% to 12% of cases of maxillary sinusitis. An odontogenic source should be considered in
individuals with symptoms of maxillary sinusitis with a history of odontogenic infection,
dentoalveolar surgery, periodontal surgery, or in those resistant to conventional therapy.
Diagnosis usually requires a thorough dental and clinical evaluation including appropriate
radiographs. The most common causes of odontogenic sinusitis include dental abcesses and
periodontal disease that had perforated the Schneidarian membrane, irritation and secondary
infection caused by intra-antral foreign bodies and sinus perforation during tooth extraction.
An odontogenic infection is a polymicrobial aerobic-anaerobic infection, wit anaerobes
outnumbering the aerobes. The most common isolates include anaerobicstreptococci and
gram-negative bacilli, and Enterobactericeae. Surgical and dental treatment of the
odontogenic pathological conditions combined with medical therapy is indicated. When
present, an odontogenic foreign body should be surgical removed. Surgical management of
oroantral communication is indicated to reduce the likelihood of causing chronic sinus
disease. The management of odontogenic sinusitis includes a 3 to 4 week course of
antimicrobials effective againts the oral flora pathogens.
One should suspect there is odontogenic sinusitis when a chronic maxillary sinusitis is
found on one side and there is purulent mucus and foul-smelling breath. To treat the sinusitis,
the infected tooth must be extracted or treated, and given antibiotics that is also effective for
anaerobic bacteria. Often times, there is a need to irrigate the maxillary sinus.
Sign and Symptom
Subjective assessment of rhinosinusitis is based on symptoms.
nasal blockage, congestion or stuffiness;
nasal discharge or postnasal drip, often mucopurulent;
facial pain or pressure, headache, and
reduction/loss of smell.

11

Besides these local symptoms, there are distant and general symptoms. Distant symptoms are
pharyngeal, laryngeal and tracheal irritation causing sore throat, dysphonia and cough,
whereas general symptoms include drowsiness, malaise and fever. Individual variations of
these general symptom patterns are many (24, 455-459). It is interesting to note that only a
small proportion of patients with purulent rhinosinusitis, without coexisting chest disease,
complain of cough.
The symptoms are principally the same in acute and chronic rhinosinusitis as well as
in CRS with nasal polyps, but the symptom pattern and intensity may vary. Acute forms of
infections, both acute and acute exacerbations of chronic rhinosinusitis, have usually more
distinct and often more severe symptoms.
Diagnosis

The recent European Position Paper on Rhinosinusitis recommends that a diagnosis of

rhinosinusitis should be based on the following[1]:
Two or more symptoms, one of which should be either nasal blockage/
obstruction/congestion or nasal discharge:
-

Facial pain/pressure
Reduction or loss of smell

Additionally, there should be objective signs of disease on nasal endoscopy

and/or paranasal CT scan.
12

Endoscopic signs of polyps; and/or mucopurulent discharge primarily from

the middle meatus; and/or edema/mucosal obstruction primarily in the

middle meatus
CT evidence of mucosal changes within the ostiomeatal complex and/or
sinuses

13

14

Treatment
Clinical Guideline from PERHATI-KL

15

The Clinical Practice Guidelines of the American College of Physicians which have been
endorsed by the Centers for Disease Control and Prevention, the American Academy of
Family Physicians, the American College of Physicians- American Society of Internal
Medicine, and the Infectious Disease Society of America, conclude that most cases of acute
sinusitis are caused by uncomplicated viral infections which do not require sinus radiography
or antibiotic treatment. Instead, treatment of symptoms with analgesics, antipyretics and
decongestants and saline lavage along with reassurance is recommended as the preferred
initial strategy for management.
Home Self Care Measures
a. Maintain adequate hydration (drink 6-10 glasses of liquid a day to thin mucus)
b. Steamy shower or increase humidity in your home or personal steam vaporizer
c. Apply warm facial packs (warm wash cloth, hot water bottle, or gel pack for 5 to 10
minutes, 3 or more times per day)
d. Analgesics (acetaminophen, ibuprofen, aspirin as needed- DO NOT USE ASPIRIN IN
CHILDREN UNDER 18 YEARS OF AGE)
e. Saline irrigation lavage
- Homemade (1/4 teaspoon salt dissolved in 1 cup of water; use bulb syringe,dropper,
Netipot or sinus rinse bottle purchased from drug store)
- Saline nasal drops/spray, commercial (e.g., Ocean, Salinex, Nasal)
f. Decongestants (oral)
i.e.: Pseudoephedrine hydrochloride (e.g., Sudafed 60 mg. every 4 to 6 hours, not to
exceed 4 doses per 24 hours.
g. Decongestant nasal sprays for no longer than 5 days, (e.g., oxymetazoline [Afrin],
phenylephrine hydrochloride (neo-Synephrine)
h. Adequate rest
i. Sleep with head of bed elevated
j. Avoid cigarette smoke and extremely cool or dry air

16

CHAPTER III
17

CASE REPORT
A. IDENTITY
Name
Age
Gender
Religion
Occupation
Adress
Date of visit

: Mr. K.
: 62 years old
: Male
: Islam
: Retiree
: Kegelan, Purworejo
: Thursday, 26 July 2012

B. ANAMNESIS

Main Complaint : Presence of purulent discharge from nose

History of Present Illness :
A week before patient came to the ENT policlinic, RSUD Saras
Husada, Purworejo, he stated that there was presence of discharge coming out
from his right nostril. The yellowish purulent discharge had a bad odour and
not constantly flowing out. The patient also complained that he had a
decreased in sense of smell. There is no complaint of the left nostril. Besides
that, the patient also had a right-sided facial pain. The patient had a history of
right upper molar tooth-ache and fever which occured 2 weeks before. Patient
denied if there is flu or cough. No complaint over ears and throat was told.
The patient was never treated before.

History of Past Illness :

o History of the same complaints (-)
o History of tooth infection (-)
o History of hypertension, diabetes mellitus, asthma and allergy (-)
History of Illness in Family Members :
o History of the same complaints (-)
o History of atopy (-)
C. PHYSICAL EXAMINATION
General Status : well conscious, adequately nourished
Vital Sign :
o Blood Pressure
: - mmHg (not measured)
o Pulse
: 112 x/min
o Respiration
: 24 x/min
o Temperature
: febrile
OTORHINOLARYNGOLOGY EXAMINATION
NOSE :
18

Nose Paranasal

Right

Left

Sinus
Inspection

Symmetry (+), Purulent

Normal

Palpation
Percussion

discharge (+)
Tenderness (+)
Pain over maxillary and ethmoid

Normal
Normal

Anterior

sinuses (+)
Edema of inferior conchae (+),

Normal

Rhinoscopy

Hyperemis mucosa (+),Purulent

discharge (+) coming out from the
middle meatus, Blood (-), Septum
deviation (-)

Posterior

Not done

Rhinoscopy

Hyperemis
mucosa (+)
Hypertrophy of
inferior conchae (+),

Purulent discharge (+)

THROAT
Lips
Tooth Ginggiva
Tongue
Uvula
Tonsil
Posterior Oropharynx
Indirect Laryngoscopy

Normal
Right upper molar II caries (+)
Normal
Normal
Normal
Normal
Normal

EAR :
Ear
Inspection
Palpation
Otoscopy
Turning fork

Right
Normal
Normal
Normal

Left
Normal
Normal
Normal
Not done
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D. DIAGNOSIS
Acute rhinosinusitis
E. TREATMENT
Management :
o Medications
o Patients education
o Follow up
o Refer patient to the dentist

Medication :
o Amoxicillin 500mg 3 d.d. Tab I
o Ambroxol 30mg 3.d.d. Tab I
o Aldisa slow-release 2.d.d. Tab I
o Eflagen 50mg 2 d.d. Tab I

Patient education :
o Treat the cause of infection which is in this case tooth infection
o Get plenty of rest
o Drink plenty of fluids
o Applying warm compresses to the face
o Sleep with head elevated

20

CHAPTER IV
DISCUSSION
In this case of acute right maxillary and ethmoid rhinosinusitis, the patient was
diagnosed by the history of illness, physical examination and radiologic finding. The chief
complaint that has been stated by the patient is presence of purulent discharge from nose. A
runny nose indicated that there was a bacterial infection in the sinuses.
The yellow colour is due to infected mucus and pus. A runny nose may dry up if the
sinus drainage channels become blocked with thick mucus. When this happens, pain and
tenderness over the infected sinus may become worse. As occured in this patient, the
complaints were getting even worse.
Patient had complained of a unilateral nasal obstruction, offensive odour, nasal
discharge (purulent), hiposmia and facial pain that become worst time after time. Symptoms
also included nagging pain of the upper teeth of the damaged side, which intensifies by
occluding teeth and mobility of the teeth.
The cause of these symptoms originates from the patients dental caries. This
condition of dental infection causes the growth of granulation tissue in the maxillary sinus
mucosal thus obstructs the cilliary movement towards the ostium and disrupts the drainage.
This contributes to the occurence of rhinorrhea, nasal obstruction and hiposmia experienced
by the patient.
Intimate anatomical relation of the upper teeth to the maxillary sinus promotes the
development of odontogenic maxillary sinus. The bony wall, separating maxillary sinus from
teeth roots varies from full absence, when teeth roots are covered only by mucous membrane,
to the wall of 12 mm. Then roots of 1st, 2nd molars and the 2nd premolars are covered only
by mucous membrane and sometimes even protrude into maxillary sinus.
Maxillary sinus usually is situated over the 1st, 2nd molar but it can reach the 3rd
molar and the 1st premolar in front or even fang tooth and maxillary sinus develops when
graining or grainmatotic periodontitis, subperiostal abscessus of these teeth occur. Maxillary
sinus also can develope because of the maxillary osteomyelitis, radicular cystis of teeth.
Maxillary sinus can develop after mechanical injury of sinus mucosa during
endodontic teeth treatment, when root canals of teeth are overfilled by tooth-filling material.
Also it can develop because of the fistulas after teeth extractions, when a tooth implant is
implanted incorrectly or other foreign-bodies that penetrated into the sinus from oral cavity

21

(fragments of dental instruments, dental roots, turundas, etc.), when in-flammation of retained
teeth occurs.
Maxillary sinus can develop after trauma of sinus walls, surgical treatment of nasal
cavity, after a nose tamponada procedure. In this case, the patient developed maxillary sinus
due to the caries in the second molar tooth. Because of the untreated tooth problem, the
maxillary sinus is infected, theinflammation of sinus develops.
In otorhinolaryngology examination, the findings were smelly purulent nasal
discharge coming out of the right nostril with rhinalgia and tendeness over palpation and
percussion of maxillary and ethmoid sinuses. On anterior rhinoscopy examination, the
enlargement of the right inferior conchae and hyperemis of the nasal mucosa can be seen.
This is due to the inflammatory process which occur as a result of the infected sinuses. In this
patient also, there is sinus pain during palpation and percussion. Palpation of the maxillary
anterior region can produce a dull pain, and percussion pieces can reveal an antral jaw pain
localized to one or more teeth.
By the inspection of the oral tissues and the lobby, looking for inflammation and
erythema, despite the fact that this finding is rarely seen in association with the maxillary
sinus. Inflammation of the soft tissue is rarely caused by maxillary sinusitis due to the
absence of veins anastomosed and connecting to the subcutaneous tissue, but chronic sinusitis
is likely to erode some of the sinus wall, causing a visible swelling of the soft tissue,
particularly at the intraoral. In this case, there is no finding of soft tissue swelling and
inflammation of oral tissue.
The treatment of the odontogen sinusitis should be focused on dental pathology and
treatment of sinusitis. The elimination of the source of infection, such as the removal of a
tooth root of the sinus cavity, the treatment of the ducts, or the extraction of tooth, is needed
to prevent the recurrence of sinusitis. The treatment of sinusitis should be focused on solving
the dental disease (reprocessing or extraction), periodontal disease, and sinus hyperplasia
(mucosa hyperplasia). This is the reason why patient was been refered to the dentist to
manage his tooth problem.
For the treatment of rhinosinusitis itself, there are 2 type of treatment, which are
surgical intervention and conservative treatment. Combined treatment (surgical intervention
and conservative treatment, which is directed at improving drainage from the maxillary sinus
by widening the natural ostium of the sinus, general treatment includes antibacterial therapy,
analgetics and hyposensitizing agents) was applied in 3.2% of the patients, while only

22

conservative treatment was applied in 9.2% of the patients. Surgical and medicamental
treatment was applied in 87.6% of the patients.
In this case, conservative treatment is choosen as a consideration that the cause of this
disease is due to the dental infection. Antibiotic is prescribed to kill the bacteria and to
eliminate the cause of infection. Symptomatic treatment also has been given to this patient to
relieve the symptoms that have been complained by the patient.

23

CHAPTER V
CONCLUSION
A 62-year-old male patient diagnosed with acute rhinosinusitis has been reported.
Acute rhinosinusitis can be determined by the complaints of presence of purulent discharge as
the main symptom, accompanied by unilateral block nose, hyposmia and facial pain.
Diagnosis can be made by the history taking, nose and throat examination and radiologic
findings. In nose and throat examination, the findings are presence of purulent discharge in
the nostril, hypertrophy of inferior conchae and hyperemis of the nasal mucosa. Therapy for
this case is conservative treatment. So the cause of infection is treated first. The patient also is
treated by symptomatic treatment to reduce the complaints.

24

REFERENCES
1. Meltzer E. O., Hamilos D. L., Hadley J. A., et al. Rhinosinusitis: establishing
denitions for clinical research and patient care. J Allergy Clin Immunol 2004;
114:155212.
2. Pleis J. R., Lucas J. W., Ward B.W. Summary health statistics for U.S. adults: National
Health Interview Survey, 2008. Vital Health Stat 10 2009: 1157.
3. Revai K., Dobbs L. A., Nair S., Patel J. A., Grady J. J., Chonmaitree T. Incidence of
acute otitis media and sinusitis complicating upper respiratory tract infection: the
effect of age. Pediatrics 2007; 119:e140812.
4. Fokkens W., Lund V., Mullol J. European position paper on rhinosinusitis and nasal
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