Case Report

Chronic Rhinosinusitis
Coass Group 15.1.07
Moderator: dr. Belinda Djimandjaja

Group Members

Irfan Haris (14639)

Atika Dwitama (14327)
Rinda Rosmayanti (13164)
Ulfah Fitriyani (14599)
Singgih Setiawan (14561)
Maruti Lintangsenjani (13467)
Cresti Chandra Pradelta (14631)

LITERATURE REVIEW

Anatomy of the Nose and Paranasal

Sinus

Chronic Rhinosinusitis

Definition

Chronic rhinosinusitis is an inflammatory

process in the mucosa of the nose and
paranasal sinuses with a duration of more
than 12 weeks or 3 months.

Etiology

Bacteria (Pseudomonas, Citrobacter,

Haemophilus, Propionibacterium,
Staphylococcus, and Streptococcus)
Air pollution
Active smoking
Passive smoking
Allergic rhinitis
Gastropharyngeal reflux

Pathophysiology

Diagnosis
Table 1. Symptoms and Signs Associated With Rhinosinusitis
(Rhinosinusitis Task Force in 1996 quoted from Bailey, et al,
2006)Minor factor
Major factor
Facial pain/pressurea
Headache
Nasal obstruction
Fever (all nonacute)
Nasal
discharge/discolored Halitosis
postnasal drip
Hiposmia/anosmia
Dental pain
Purulence in examination
Fatigue
Fever (acute only)b
Cough

Ear pain/pressure/fullness
a: The presence of facial pain / pressure without any other major symptoms and
signs cannot be used to direct the diagnosis.
b: The presence of fever in sinusitis / acute rhinosinusitis without any symptoms
and signs another major, cannot be used to direct the diagnosis.

The diagnosis of rhinosinusitis based on the above criteria is

established when it is found that there are two or more major
symptoms, or one major symptom accompanied by two minor
symptoms.

Diagnosis

Based on Task Force 2007, the chronic rhinosinusitis is

inflammation which twelve (12) weeks or longer of
two or more of the following signs and symptoms:

Mucopurulent drainage (anterior, posterior, or both)

Nasal obstruction (congestion)
Facial pain-pressure-fullness
Decreased sense of smell

AND inflammation is documented by one or more of

the following findings:

Purulent (not clear) mucus or edema in the middle meatus

or ethmoid region
Polyps in nasal cavity or the middle meatus
Radiographic imaging showing inflammation of the
paranasal sinuses

Diagnosis

Chronic rhinosinusitis, with or without nasal polyps in adults

is defined as:

for 12 weeks
This should be supported by demonstrable disease. Either
endoscopic signs of:

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

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

(EPOS, 2012)

Management

Complications

Local Complications
- Mucocele
- Osteomyelitis (when occurs in frontal bone, known as
Pott's puffy tumor)
Orbital Complications
- Preseptal cellulitis
- Orbital cellulitis
- Subperiosteal abscess
- Orbital abscess
- Trombophlebitis cavernous sinus
Intracranial Complications
- Meningitis
- Subdural abscess
- Epidural abscess
- Intracerebral abscess
- Cavernous sinus thrombosis / venous

CASE REPORT

Patient Identity

Name
Age
MR
Sex

:
:
:
:

M
25 years old
73-XX-XX
Female

Anamnesis

Chief complain
: runny nose
History of present illness:

Since approximately 6 months before came to ENT

clinic of RSUD Banyumas, patient had recurrent
runny nose, stinky and yellowish-green colored
discharge, and nasal blockage. Patient also
complains about unpleasant odor in her nose and
pain over right and left cheeks, and mucus on her
throat. There are no complains about ear and
throat. She never been treated before.

Anamnesis

History of past illness :

She denies alergy, asthma, and toothache history.

History of family illness :

Her family do not have diabetes mellitus,

hypertension, and allergy.

Resume of Anamnesis

Female patient with symptoms of rhinorrhea,

nasal congestion, foeter ex nasale, and
mucous on her throat.

Physical Examination

General status : good, compos mentis

Vital sign

BP
: 120/70 mmHg
Respiratory Rate : 20 times/minute
Temperature : 36,5C
Pulse
: 64 times/minute.

ENT Examination

Right and left ears : within normal limit.

Anterior rhinoscopy: hyperemic in right and
left nasal cavity, edematous inferior turbinate
in the right and left nasal cavity, septum
deviation (-), discharge (+), mass (-)
Posterior rhinoscopy: discharge (+),
edematous concha (+)
Facial palpation and percusion: pain over right
and left cheek
Oropharyngeal examination: palatine tonsils
size are within normal limit, good gag reflex,
post nasal drip (+)
Indirect laryngoscopy: within normal limit

Diagnosis

Chronic rhinosinusitis without nasal polyp

Treatment

Amoxicillin-clavulanate acid 625 mg every 8

hours
Trifed (pseudoefedrin HCL 30 mg + tripolidine
20 mg) every 8 hours
Ambroxol 30 mg every 8 hours

Problem

Recurrency

Plan

Control to ENT clinic for evaluation 1 week

later and skin prick test 1 week after the end
of treatment.

DISCUSSION

This patient is diagnosed with chronic

rhinosinusitis based on her signs and
symptoms, which are recurrent rhinorrea,
nasal congestion, foul-smelling and yellowishgreen colored discharge. Patient also
complains about unpleasant odor in her nose,
pain over right and left cheeks, and mucus on
her throat. There are no complains about ear
and throat. She denies alergy, asthma, and
toothache history.

Problem in this case is recurrency

Factors that contribute to recurrency of
chronic rhinosinusitis consists of:

host factors (genetic factors, physiologic factors,

structural factors, defects in innate imunity, and
defects in adaptive immunity);
environmental factors (allergy, smoking,
irritants/pollution); and
microbial factors (bacteria, fungi, biofilms, and
superantigens)

We think that the patient has allergy as the

factors that contribute to recurrency of her
chronic rhinosinusitis.
The relationship between allergic rhinitis with
rhinosinusitis has been widely studied and
recorded although a causal relationship
cannot be state certainly.
In patients with chronic rhinosinusitis, allergic
rhinitis prevalence ranged between 25-50% .
In patients undergoing sinus surgery, the
prevalence of positive skin test results ranged
between 50-84%, the majority (60%) with
multiple sensitivity.4

But how allergies can cause chronic

rhinosinusitis, to this day is not known clearly.
One hypothesis state that nasal mucosal
edema in patients with allergic rhinitis that
occurs in the sinus ostium can reduce
ventilation even lead to obstruction of the
sinus ostium, resulting in retention of mucus
and infetion. However this is more directed to
acute rhinosinusitis, while the extent of the
development and persistence of state gives
the effect of chronic rhinosinusitis, has yet to
explain.

CONCLUSION

We report a 24 years old female patient with runny

nose as a main complain; recurrent foul smelling and
yellowish-green colored snot, and nasal blockage. since
6 months ago. Patient also complains about unpleasant
odor in her nose and headache everytime she bents her
neck, pain over right and left cheeks, and mucus on her
throat. From anamnesis andphysical examination, we
diagnosed chronic rhinosinusitis. The treatment for this
case was Coamoxiclav 625 mg every 8 hours, Trifed
(pseudoefedrin HCL 30 mg + tripolidine 20 mg) every 8
hours, and Ambroxol 30 mg every 8 hours a day. We ask
patient to follow our advice, control her treatment
regularly at ENT clinic of RSUD Banyumas, and skin prick
test 1 week after the end or treatment.

REFERENCES

Kashani S, et al. Clinical Characteristics of Patients with Chronic

Rhinosinusitis and Specific Antibody,
Journal of Allergy and Clinical Immunology Volume 129, Issue 2,
February 2012, Pages AB68
Brook, Itzak, et al. Sinusitis From Microbiology to Management.
New York: Taylor and Francis, 2006.
Ballanger JJ. Hidung dan sinus paranasal. Dalam Penyakit Telinga,
Hidung, Tenggorok, Kepala dan Leher Jilid 1 edisi 13, Binarupa
Aksara 1994; hal 1-27.
Kristyono I, Selvianti. Patofisiologi, diagnosis dan penatalaksanaan
rhinosinusitis kronik tanpa poli nasi pada orang dewasa, Karya
Tulis Ilmiah, 2013.
Saladin K. Saladin: Anatomy & Physiology: The Unity of Form and
Function. 3rd ed. New York: McGraw-Hill; 2003.
Vander AJ, Sherman JH, Luciano DS. Human Physiology: The
Mechanism of Body Function. 8th ed. New York: McGraw-Hill; 2001

Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology. 5th

ed. Philadelphia: Williams & Wilkins, 2014.
Rhinology Study Group PERHATI-KL 2007, Buku Saku EPOS 2007,
PERHATI-KL, Jakarta.
Shah DR, Salamone FN, Tami TA. Acute & chronic rhinosinusitis. In
Lalwani AK, eds. Current diagnosis and treatment in otolaryngology
head and neck surgery. New York: Mc Graw Hill, 2008; 273-281
Fokkens WJ, et al. 2012, European Position Paper on Rhinosinusitis
and Nasal Polyps 2012. Rhinology 50; suppl. 23: 1-298.
Busquets JM, Hwang PH. Nonpolypoid rhinosinusitis: Classification,
diagnosis and treatment. In Bailey BJ, Johnson JT, Newlands SD, eds.
Head & Neck Surgery Otolaryngology. 4 th ed. Vol 1. Philadelphia:
Lippincott Williams & Wilkins, 2006; 406-416.
Hamilos L Daniel, 2011, Chronic Rinosinusitis : Epydemiology and
Medical Management, Journal of Allergy and Clinical Immunology
Volume 128, Issue 4, October 2011, Pages 693-707

THANK YOU

BACK UP SLIDE

Tabel 2. Terms for Diagnosis Chronic Rhinosinusitis (2003 Task Force)

Duration
Objective findings
1. The presence of purulent secretions
nasal cavity, polyps or polypoid
growth in rhinoscopy examination
(with dekongesti) or endoscopy
Ongoing symptoms or
clinical
signs
continuously for> 12
weeks in accordance
with the criteria of the
Task Force 1996

2. The presence of edema or erythema

at the meatus media during
One of the
endoscopic examination
criteria
in
addition to be 3. The presence of edema, erythema,
or granulation tissue either localized
found:
or difusa in the nasal cavity. If it does
not involve media meatus, the
imaging examinations required for
diagnosis.

4. Imaging studies to confirm the

diagnosis. (Plain photo or CT-Scanb)
a Plain without any other objective findings (1,2, and 3) can not be used for
diagnosis.